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KDITED  BY 

JOHN  D.  COMRIE,  M.A.,  B.Sc,  M.D.,  F.R.C.P.  (Edin.) 
DISEASES  AND  INJURIES  OF  THE  EYE 

.\  Text-Tiook  for  Students  and  Practitioners.  By  William  George 
Sym,  M.D.,  F.K.C.S.E.,  Ophthalmic  Surgeon,  Edinburgh  Royal  Infirm- 
ary: Lecturer  on  Diseases  of  the  Eye  in  the  L'niversity  of  Edinburgh. 
Crown  8vo,  cloth,  containing  25  full-page  Illustrations,  16  of  them  in  col. 
our,  and  88  figures  in  the  text:  also  a  Type  Test-Card  at  end  of  volume. 

PRACTICAL  PATHOLOGY.  MORBID  ANATOMY. 
AND  POST-MORTEM  TECHNIQUE 

A  Text-  Hook  for  Students  and  Practitioners.  By  James  Miller, 
.M.D..  E.R.C.P.E..  Assistant  Pathologist  to  the  Edinburgh  Royal  In- 
firmary: Lecturer  on  Pathology  in  the  School  of  Medicine  of  the  Royal 
Colleges,  Edinburgh.  Crown  8vo,  cloth.  Containing  in  Illustrations, 
and  a  Frontispiece  in  colour. 

A  TEXT-BOOK  OF  MIDWIFERY 

For  Students  and  Practitiones.  By  R.  W.  Johnstone,  M.A.,  M.D.. 
F.R.C.S.E.,  ALR.C.P.E..  Assistant  to  the  Professor  of  Midwifery  and 
to  the  Lecturer  on  Gynecology  in  the  University  of  Edinburgh;  Extern 
Assistant  Physician.  Royal  Maternity  Hospital:  Obstetric  i^hysician. 
New  Town  Dispensary:  University  Clinical  Tutor  in  Gynaecology,  Royal 
Infirmary:  Gyntecologist,  Livingstone  Dispensary.  Edinburgh.  Crown 
8vo,  cloth,  containing  264  Illustrations. 

RADIOGRAPHY,  X-RAY  THERAPEUTICS  AND 
RADIUM  THERAPY 

A  Handbook  for  Students  and  Practitioners.  By  Robert  Knox,  M.D.. 
(Edin.),  M.R.C.S.  (Eng.).  L.R.C.P.  iLond.).  Hon.  Radiographer. 
King's  College  Hospital;  Director,  Electrical  and  Radiotherapeutic 
Department.  Cancer  Hospital,  London:  Hon.  Radiographer.  Great 
Northern  Central  Hospital,  London.  Containing  60  Plates  and  50  Illus- 
trations.    Super  royal  8vo.  cloth. 

THE  LAWS  OF  HEALTH  FOR  SCHOOLS 

By  A.  ^L  Malcolmson.  M.D.     Small  crown  8vo,  cloth,  illustrated. 

This  book,  intended  for  the  teaching  of  the  ordinary  rules  wh  ch  guide 
one  in  the  care  of  the  general  health,  has  been  written  specially  for  use  in 
schools.  Elementary  anatomy  and  physiology  have  been  described  only  in 
so  far  as  these  were  deemed  essential  to  a  sufficient  understanding  of  the 
methods  used  for  the  preservation  of  health. 

Other  I'olumes  in  Preparation 
The  Macmillan  Company,  64-66  Fifth  Ave.,  N.  Y. 


^f)e  Cbinburgf)  ifflebtcal  ^trit& 

General  Editor. — Jons  D.  Comrie 

M.A..   B.SC.   M.D.,    F.B.C.P.E. 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

IN  CHILDREN 


^9  '^"*   o  ■  ■ 

THE  MACMILLAN   COMPANY 

NEW  VOKK    •    BOSTON    ■    CHICAC;0 
DALLAS    •    SAN  FRANCISCO 

MACMILLAN  &  CO..  Limited 

LONDON    •    BOMBAY    ■    CALCUTTA 
MELBOURNK 

rilE  MACMILLAN  CO.  OF  CANADA.  Ltd. 

TORONTO 


TUBERCULOSIS 


OF  THE 


BONES    AND     JOINTS 
IN    CHILDREN 


BY 

JOHN  FllASER,   M.D.,  F.R.C.S.E.,  Ch.M. 

ASSISTANT  SriU;EC)X.    IIOYAl.    HOSI'ITAL    FOIl    SICK   lllIinilEX.    EDIMinUill 


WITH  .-,1   Fl'I.l.-I'A(;i'.  PLATES  (•.'  IN  COI.OHi  AND  KU  FICIUKS 
IN"    TIIK     TEXT 


i2cU)  porU 

THE    MACMILLAN    COMPANY 

1914 

All  rlijh's  risfrreil 


TO 

HAROLD  J.  STILES,  M.B.,  F.R.C.S.E. 

SURGEON    TO    THE    ROYAL    HOSPITAL    FOR    SICK    CHILDREN 

ANU    CHALMERS    HOSPITAL,    EDINBURGH,    ETC. 

THIS    VOLUME    IS    DEDICATED 

IN    TOKEN    OF    HIGH    ESTEEM    AND    AFFECTIONATE    REGARD 


PREFACE 

Some  years  ago,  through  the  kindness  of  Mr.  Stiles,  I  was  enabled  to  carry 
out  an  investigation  of  a  number  of  cases  of  tuberculous  disease  of  the  bones 
and  the  joints.  The  pathological  and  etiological  aspects  of  these  studies 
were  presented  as  a  Thesis  for  the  degree  of  M.D.  of  Edinburgh  University 
in  the  year  1912,  and  a  number  of  isolated  papers  have  been  published  in 
various  periodicals. 

The  disease  was  also  observed  from  the  clinical  aspect,  and  a 
combination  of  these  two  investigations  has  resulted  in  the  publication  of 
the  present  work.  I  recognised  that  a  collation  of  experimental  and  patho- 
logical results  were  of  little  value  unless  combined  with  the  more  practical 
clinical  side. 

The  present  work  deals  with  the  disease  purely  as  it  occurs  in  children, 
and  this  accounts  for  the  omission  of  regional  diseases  which  do  not  occur  in 
childhood,  e.<j.  tuberculosis  of  the  patella. 

The  Ijook  is  divided  into  two  portions  :  a  consideration  of  the  disease 
from  the  general  aspect,  and  an  investigation  of  it  as  it  appears  in  individual 
regions.  At  the  end  of  each  section  there  is  a  compilation  of  the  more  recent 
literature  dealing  with  the  subject ;  the  author  wishes  it  to  be  clearly  under- 
.stood  that  he  has  not  personally  consulted  all  of  these  references,  they  are 
added  to  improve  the  value  of  the  work  from  a  consultation  point  of  view. 

I  have  dedicated  this  book  to  Mr.  Stiles,  siu-geon  to  the  Children's 
Ifospitai  and  to  ('halnuT.s  Hospital,  and  I  cannot  make  too  complete 
acknowledgment  ol  my  indebtedness  to  liim.  iic  originally  embarked 
me  on  the  study  ;  \\v.  gave  me  access  to  tiie  valuable  specimens  which  he 
has  such  a  uniipie  o[iportunity  of  obtaining  ;  and  during  the  pathological 
investigation.s  he  repeatedly  gave  me  the  benefit  of  his  wide  pathological 
knowledge.  The  illustrations,  with  few  excei)tionH,  I  owe  directly  or  in- 
directly to  him.      In  lad  mic  iiuiy  say  that  to  liini  tin'  1 k  owes  any  value 

vii  a2 


viii  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

it  may  possess,  while  he  is  in  no  way  responsible  for  any  errors  or  heterodoxy 
which  it  may  contain.  The  experimental  part  of  the  work  was  carried  out 
in  the  Laboratory  of  the  Royal  College  of  Physicians,  and  I  owe  thanks  to 
Professor  James  Ritchie,  the  superintendent,  for  much  encouragement  and 
assistance.  In  the  literary  part  of  the  work  I  have  repeated  Idndnesses  to 
acknowledge.  Dr.  John  D.  Comrie  assisted  me  in  the  reading  and  arrange- 
ment of  the  proofs,  likewise  Dr.  Seelenmeyer.  Dr.  John  Spence  and  Dr. 
Archibald  McKendrick  were  good  enough  to  give  me  the  benefit  of  their 
advice  in  the  compilation  of  that  portion  of  the  work  which  deals  with  X-ray 
examination.  The  index  has  been  arranged  by  Dr.  James  McBain  Ross. 
Sister  Smith  of  the  Sui'gical  Out-patient  Department  of  the  Children's 
Hospital  has  given  me  invaluable  assistance  in  the  photographing  and 
arranging  of  the  clinical  studies.  The  illustrations  have  been  produced  by 
Mrs.  Marshall  Brown,  Mr.  Richard  Muir,  and  the  late  Mi-.  Robert  Lindsay. 
I  have  to  acknowledge  my  indebtedness  to  the  Editors  and  Proprietors 
of  the  Journal  of  Pathology  and  Bacterioloyii  for  permission  to  use  a  number 
of  plates  illustrative  of  an  article  published  in  their  Journal.  Much  of  the 
expense  necessarily  entailed  in  a  work  of  this  description  has  been  borne 
by  grants  from  the  Carnegie  Trust  and  the  McCunn  Scholarships.  I 
make  grateful  acknowledgment  of  their  assistance.  To  the  Publishers  I 
owe  thanks  for  their  courtesy  and  continued  attention. 

JOHN  ERASER. 

3  Daknaway  Stiiee'I',  EniNEur.GH, 
May  191-i. 


CONTENTS 


PART    I.— UENE1!A1> 

Etiology   .....  ...            3 

The  Pathiii.ouy  of  Tuberculosis  of  Bone            .  .             .              .11 

Tuberculous  Diaphysitis               .              .  ...         33 

The    PATHOLOIiY    OF    TUBERUUL0.SIS    OF    JoiXT.S              .  .                    .                    .34 

The  Clinical  Features  of  Bone  Tiuerculosis  .  .              .              .44 

The  Clinical  Features  of  Joint  Tiiierculcsis  .  .             .              .          4G 

The  Uiaqno.sis  of  Bone  Tubekcolosis     .              .  .              .              .50 

The  Diagnosis  of  Joint  Tuberculosis    .              .  .              .              .         b-i 

The  X-Ray  Appearances  in  Negatives  of  Tuberculous  Bones  and  Joints        08 

Prognosis  in  Bone  and  Joint  Tdberculosis        .  .              .              .64 

Treatment  of  Bone  Tuberculo.sis              .              .  .              .              .65 
Treatment  of  Joint  Tuberculosis            .....        100 


i'AKT    lI.—SrEClAi 

Ti'BERCiLous  Disease  of  the  Spine 

Hip-Joint  Disease 

Tuberculous  Disease  of  the  Knee-joint' 

Tuberculous  Disease  of  the  Ankle-joint 

Tuberculous  Disease  of  the  Tarsu.s 

Tuberculous  Disease  op  the  Long  Bones  of  ti 

Tuberculous  Disease  oir  the  Shoulder-joint 

Tuberculous  Disease  of  the  Elbow-joint 

Tuberculous  Disease  of  the  Wrist-joint 

Sacro-iliac  Dlsease 

Tuberculous  Disease  of  the  Skull-p.ones 

Tuberculous  Disease  of  the  Lower  Jaw 

Tuberculous  Disease  of  the  Upper  Jaw  and  .\Iaiah   1 

Tuberculosis  of  the  Kids 

GENERAL  INDK.X 
INDKX  Ol'  AUTHORS  . 


K   Hand  and  1' 


111 
204 
258 
281 
290 
297 
304 
312 
319 
324 
328 
330 
333 
33  1 

337 
347 


LIST   OF   ILLUSTRATIONS 


PLATES 


FACING   PAOE 


I.  The  Normal  Anatomy  of  the  End  of  a  Long  Bone,  etc. 

n.  The  Scheme  of  the  Arterial  Blood-supply  of  Bones 

m.  A  Volkmami's  Canal  in  Section  .... 

IV.  The  Histology  of  the  Original  Tubercle 

V.  The  Histology  of  the  Original  Tubercle 

VI.  Secondary  Changes  in  the  Tuberculous  FoUicle 

vu.  Marrow  Changes  in  Tuberculous  OsteomyeUtis 

vm.  The  Rarefaction  of  Bone  ..... 

IX.  The  Lamellar  ('hanges  secondary  to  Tuberculous  Osteomyelitis 

X.  The  Stages  in  the  Formation  of  new  Subperiosteal  Bone   . 

XI.  The  Final  Picture  of  new  Subperiosteal  Bone 

xn.  The  Vascular  Changes  secondary  to  Tuberculous  OsteomyeUtis    . 

xm.  Corona!  Section  through  Head  of  Femur,  etc.  .... 

XIV.  The  Stages  in  the  J)evelopment  of  an  Encysted  Tuberculous  Disease  of  tho 

Bone      .      •      . 

XV.  Infiltrating  Tuberculous  Disease  of  tlic  Bone 

XVI.  Infiltrating  Tul)erculosis  of  Bono         .... 

xvn.  Infiltrating  Tuberculous  Disease  of  the  Bone 

xvm.  The  Atrophic  Type  of  Tuberculosis  of  Bone 

XIX.  The  Aijpearance  of  the  Marrow  in  Atrophic  Tuborculo.sis  . 

XX.  Atrophic  Tuberculous  Disease  of  the  Bone    . 

XXI.  Hy^jertrojihic  Tuberculosis  of  the  Tibia 

XXII.  Hypertrophic  Tuberculosis  of  the  Til)ia 

xxm.  Stages  in  tho  Dovolojimcnt  of  Hypertrophic  'J'uburculosis  . 

XXIV.  A  FuUy-doveloped  Hypertrophic  Tuberculosis  of  tho  Tibia 

XXV.  Sequestrum  Formation  ...... 

XXVI.  Extensive  Sequestrum  Korination  in  flu-  liil(ii(ji- of  (lie  l<"(iiuir    .      J 

xxvn.  Tuberculow.'i  Dactylitis   ........ 

XXVIII.  The  Anatomy  of  I  lie  Articular  ami  Kpiphyseal  Regions 

XXIX.  Tuberculous  Disease  of  the  Synovial  .Membrane       .... 

XXX.  Changes  in  the  Cartilage  secondary  to  Tuberculous  DLscaso  of  the  Joint 

XXXI.  Tuberculous  Disease  of  Joint.s  .....        {Coloured) 


(Coloured) 


10 
12 
14 
16 
17 
18 
19 


Between 
20  &  21 


22 
23 

24 
25 
25 


Between 
24  &  25 

26 

27 

Between 

28  &  29 


32 
;!3 
35 
36 
38 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


xxxu.    Tuberculous  Disease  of  the  Synovial  Membrane 
xxxni.  The  Varieties  of  Tuberculous  Disease  of  Joints 
XXXIV.  The  Varieties  of  Tubei'culous  Disease  of  Joints 
XXXV.  The  X-Ray  appearance  of  early  Tuberculous  Disease  of  the  Bone 
xxx\^.  The  X-Ray  appearance  of  new  Subperiosteal  Bone 
XXXVII.  The  X-Ray  appearance  of   Tuberculous  Disease   of   the    Bone 

associated  with  Sequestrum  Formation  and  a  Cavity    . 
xxxvrn.  The  X-Ray  appearance  of  Hypertrophic  Tuberculosis  of  the  Tibia 
xxxix.  The  X-Ray  appearance  of  Atrojihic  Tuberculous  Disease  of  the 
upper  end  of  the  Uhia  ...... 

XL.  The  X-Ray  appearance  of  Early  Tuberculous  Disease  of  the  Knee-Joint 
XLi.  The  X-Ray  appearance  of  an  Advanced  Tuberculosis  of  the  Knee-.Toint 
XLii.  The  Stages  in  the  making  of  a  Plaster  Case  .  .  .  . 

XLiii.   The  Pathological  Varieties  of  Pott's  Disease  .  .  .  . 

XLiv.  Advanced  Tuberculous  Disease  of  the  Ankle-Joint 
XLV.  Tuberculous  Disease  of  the  Ankle-joint       .  .  .  .  . 

XLVI.   Tuberculous  Dactylitis  affecting  the  Proximal  Phalanx  of  the  Finger  . 
XLVii.  The  X-Ray  appearance  of  Tuberculous  Dactylitis 
SLViu.  The  X-Ray  appearance  of  Tuberculous  Disease  of  the  Shoulder-Joint 
XLix.  The  Pathology  of  Tuberculous  Disease  of  the  Elbow-Joint 
L.   Advanced  Tuberculous  Disease  of  the  Elbow-Joint 
LI.   Tuberculous  Disease  of  the  Lower  Jaw         .  .  .  .  . 


FArlNn  FAOK 

.       38 

40 

.       41 

.       58 


Between 
60  &  61 


62 
63 
70 
114 
282 
284 
299 
302 
303 
312 
314 
330 


IN  THE  TEXT 


1.  The  Original  Culture  Test   . 

2.  Pacinian  Bodies  in  the  Periosteum 

3.  A  Developing  Perivascular  Tubercle 

4.  Bier's  Passive  H3rper;Temia  applied  to  the  Uppfii:  Extremity 
o.  The  Technique  of  Abscess  Aspiration 

6.  Methods  of  applying  Extension  Plastei'S  . 

7.  Dorsal  Pott's  Disease  affecting  several  Vertcbrse 

8.  Dorsal  Pott's  Disease  affecting  a  single  Vertebra 

9.  Scohosis  in  Pott's  Disease   ..... 

10.  The  Kinking  of  the  Great  Vessels  secondary  to  Tuberculous  Disease  of  the 

Vertebrse     ....... 

11.  Thoracic  Deformity  in  Dorsal  and  Dorso-Lumbar  Kyphosis 

12.  The  Arrangement  of  the  Cervical  Fascia 

13.  The  Distribution  of  the  Posterior  Primary  Divisions  of  the  Dorsal  Nerves 

14.  The  Relations  of  the  Fascise  in  regard  to  the  Development  of  Abscesses 

secondary  to  Pott's  Disease 

15.  The  Arrangement  of  the  Lumbar  Fascia 


4 

14 

17 

74 

78 

101 

115 

115 

116 

118 
119 
121 
123 

124 
125 


LIST  OF  ILLUSTRATIONS 


Dorso 


FItt. 

16.  Large  Psoas  Abscess  originating  in  Tuberculous  Disease  of  the  Lumbar  Spine 

17.  The  Position  of  the  Head  iu  Various  Varieties  of  Cervical  Disease    . 

18.  Characteristic  Elevation  of  the  Shoulders  in  High  Dorsal  Pott's  Disease 

19.  The  Characteristic  Attitude  of  High  Dorsal  Disease 

20.  Dorso-Luinbar  Pott's  Disease         .... 

21.  High  Dorsal  Pott's  Disease  .... 

22.  Mid-Dorsal  Pott's  Disease.     SUght  Deformity    .    . 

23.  Low  Dorsal  Disease  with  Spinal  Rigidity  and  no  K3rphosis 

24.  Low  Dorsal  Pott's  Disease  with  Marked  Deformity 

25.  Low  Dorsal  Disease  ...... 

26.  Dorsal  Pott's  Disease  with  SUght  ScoUosis 

27.  Dorsal  Pott's  Disease  with  Marked  Scoliosis 

28.  Early  Kyphosis  in  Pott's  Disease  .... 

29.  An  Unusual  Form  of  Gibbosity  in  Pott's  Disease 

30.  Active  Flexion  of  the  Healthy  Spine  showing  a  Uniform  and  complete  Curve 

31.  Passive  Extension  in  a  Healthy  Spine 

32.  Young's  Apparatus  for  Recording  the  Extent  of  a  Spinal  Deformity 

33.  Free  Lateral  Movement  of  the  Healthy  Spine 

34.  Passive  Extension   of   the   Spine   demonstrating    Boarding   due   to 

Lumbar  Pott's  Disease     ..... 

35.  Position  Test  for  Cervical  Disease — patient  lying  prone 

36.  Position  Test  for  Cervical  Disease — patient  lying  supine 

37.  Bed  arranged  for  Recumbency  Treatment  of  Pott's  Disease 

38.  Head  Extension  apphed  for  Cervical  Tuberculous  Disease 

39.  Tubby's  Spmal  Pillow 

40.  Fisher's  Bed  Frame  . 

41.  Tlio  IJouble  Hamilton  Splint 

42.  The  Double  Thomas  Splint 

43.  A  Modified  Double  Tliomas  SpUnt 

44.  The  Bradfoici  Bed-Frame    . 

45.  The  Bradford  Bed-Frame    . 

46.  The  Bradford  Bed-Frame    . 

47.  The  Whitman  Frame 

48.  Sayre's  Cuirass 

49.  Phelps'  Plaster  Bod  . 

50.  Gauvain's  Spinal  Board 

51.  Gauvain's  Back-door  Splint 

52.  Gauvain's  Posterior  Suspensory  Splint 

53.  Gauvain's  Wheelbarrow  Splint 

54.  Phelps'  Box    .... 

55.  Pliclps'  Box  with  Paticnl  in  po.sition 

56.  The    U-Sb,i|icd   Pillow   for   tlie  Trcalm 

Cx'rvical  Sjiine 


1.  of  Tuberculous  Disoaao  of  tlie 


PAOE 

126 
131 
131 
131 
132 
132 
133 
133 
133 
133 
134 
134 
134 
134 
135 
136 
137 
1.38 

138 
139 
139 
149 
150 
150 
151 
152 
152 
153 
153 
154 
154 
155 
155 
156 
157 
158 
159 
159 
160 
160 

161 


xiv  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

Fin.  PA(iF. 

57.  Gauvain's  Apparatus  for  the  Gradual  Assumption  of  the  Vertical  Position  .  162 

58.  Suspensory  Sling  applied  in  preparation  for  the  Application  of  the  Plaster 

Jacket         ..........  165 

59.  The  "  Minerva  "  Plaster  Jacket  applied  .  .  .  .  .  .166 

60.  The  "  Minerva  "  Plaster  Jacket  appUed — Lateral  View  .  .  .166 

61.  The  "  Fillet  "  Plaster  Jacket  applied 167 

62.  The  Hani  mock  Frame  Method  of  applying  the  Plaster  Jacket  .  .168 

63.  Ridlon's  Bridge  for  supporting  the  Patient  during  the  AppUoation  of  a 

Plaster  Jacket        .  .  .  .  .  .  .  .  .168 

64.  A  Modification  of  the  Brackett  Apparatus  for  applying  a  Plaster  Jacket    .  170 

65.  An tero- Posterior  Brace  fitted  with  the  Taylor  Ring      ....  171 

66.  Davies'  Quadrilateral  Brace            .......  173 

67.  Thornton's  Back  Brace  for  Pott's  Disease           .....  174 

68.  Thomas  Cuirass  showing  the  framework  before  it  is  covered  with  leather     .  176 

69.  The  Complete  Thomas  Cuirass       .......  176 

70.  The  Making  of  a  Plaster  Cast  in  Potfs  Disease  .  .  .  .177 

71.  The  Plaster  "  Negative  " 177 

72.  The  Completed  "  Positive  " 178 

73.  The  Plaster  "  Positive  "  covered  with  the  original  layers  of  "  Stockingette  " 

and  Gauze  ..........  178 

74.  The  Flexible  Convalescent  Back  Brace  for  Pott's  Disease       .           .            .  179 

75.  The  Jury-Mast  with  chest  piece  for  incorporation  in  a  Plaster  Jacket          .  180 

76.  The  Taylor  Brace  with  the  Jury-Mast  attached             ....  181 

77.  The  Posterior  Spine  Brace  with  Taylor  Ring  attachment        .            .            .  181 

78.  The  Wire  Chin  Rest 183 

79.  The  Goldthwait  Head  Support  for  Cervical  and  Cervico-Dorsal  Disease       .  183 

80.  The  Thomas  Collar  for  Cervical  Pott's  Disease  .....  184 

81.  Incision  for  Retro-Pharyngeal  Abscess     ......  192 

82.  Incision  for  Supra-Clavicular  Abscess        ......  193 

83.  Incision  used  in  the  operation  of  Costo-Transversectomy         .            .            .  194 

84.  Incision  for  the  Evacuation  of  a  Sub-Costal  Abscess    ....  196 

85.  Incision  for  the  Evacuation  of  an  Ihao  Abscess  secondary  to  Tuberculous 

Disease  of  the  Vertebra-  ........  197 

86.  The  Hip-Joint 205 

87.  The  early  variety  of  Limp  in  Right  Hip-Joint  Disease             .           .           .  208 

88.  The  Gait  in  advanced  Hip-Joint  Disease             .....  208 

89.  "  Position  of  Self-Protection  "  in  Hip-Joint  Disease      ....  209 

90.  "  Position  of  Self-Protection  "  in  an  advanced  case  of  Hip-Joint  Disease      .  209 

91.  Position  of  the  Limb  associated  with  Tuberculous  Disease  of  the  Right 

Hip-Joint 210 

92.  Position  of  the  affected  Limb  in  advanced  Hip-Joint  Disease            .           .  211 

93.  The  Gait  in  advanced  Left  Hip- Joint  Disease    .  .  .  .  .211 

94.  Alteration  of  the  Contour  of  the  Buttock  in  Left  Hip-Joint  Disease             .  212 


LIST  OF  ILLUSTRATIONS  xv 


PACE 


95.  Thomas's  Test  to  demonstrate  the  persistent  muscular  spasm  producing 

flexion  of  the  Right  Hip-Joint  in  Hip-Joint  Disease             .            .            .  213 

96.  The  Manoeuvre  to  demonstrate  the  movements  of  rotation  at  the  Hip-Joint  214 

97.  The  Amount  of  Adduction  which  may  exist  in  Hip-Joint  Disease          .            .  216 

98.  Simple  Traction  applied  in  the  Treatment  of  Hip-Joint  Disease        .            .  222 

99.  Right-angled  Traction  in  the  Treatment  of  Hip-Joint  Disease            .            .  223 

100.  The  Long  Plaster  Bandage  applied  in  the  Treatment  of  Hip-Jomt  Disease  224 

101.  Thomas  Hip  Splint .224 

102.  Thomas  Hip  SpUnt — a  "  Nurse  "  and  Abduction  Wing  are  attached            .  225 

103.  Traction  Hip  Sphnt 226 

104.  The  Ridlon  Long  Traction  Hip  SpUnt     .  .  .  .  .  .226 

105.  The  Shaffer  Hip  SpUnt 226 

106.  The  Judson  Hip  Sphnt  with  Perineal  Crutch      .  .  .  .  .227 

107.  The  Judson  Traction  Hip  Splint    .......  227 

108.  The  Short  Plaster  Spica      ........  229 

109.  Bradford's  Abduction  Sphnt  for  Tuberculous  Disease  of  the  Hip-Joint         .  231 

110.  The  Phelps  Traction  Hip  SpUnt     .  .  .  .  .  .  .232 

111.  Dane's  Hip  SjiUnt     .........  233 

112.  Convalescent  SpUnt  with  Attachment  on  Shoe  .....  233 

113.  The  Tubular  Hip  SpUnt  for  use  in  the  Convalescent  Treatment  of  Hip- Joint 

Disease         ..........  234 

114.  The  Combination  Ridlon  SpUnt     .......  234 

115.  Combined  Thomas  Knee  and  Hip  SpUnt  for  use  in  Hip  Disease  and  Knee 

Disease  on  the  same  side            .......  234 

116.  The  Convalescent  Hip  SpUnt          .......  235 

117.  Incision  for  Anterior  Excision  of  the  Hip- Joint             ....  244 

118.  Excision  of  the  Hip  by  the  Anterior  Route — Steps  in  the  Dis.section           .  244 

119.  Incision  for  Excision  of  the  Hip  by  the  External  Route          .            .            .  245 

120.  Excision  of  the  Hip  by  the  External  Route.     Steps  in  the  Dissection          .  246 

121.  Kocher's  Incision  for  Posterior  Excision  of  the  Hi2)-Joint       .            .            .  247 

122.  Excision  of  the  Hip  by  the  Posterior  Route.     Steps  in  the  Dissection         .  248 

123.  The  Knee-Joint         .........  258 

124.  Early  Tuberculous  Disease  of  the  Kneo-Joint     .....  260 

125.  The  Deformity  of  Flexion  in  early  Knec-Joint  Disease            .           .            .  260 

126.  Tuberculous  Disease  confined  to  the  Synovial  Jlcmbrane  of  the  Knee-Joint  261 

127.  Tuberculous  Disease  of  the  Kncc-.Joint  witli  t\u-  .Aciuuiulation  of  Fluid  in 

the  Johit     ..........  261 

128.  Advanced  Tuberculous  Disease  of  the  Knee-Joint          ....  262 

129.  The  Thomas  Kneo  Splint  viewed  antero-posteriorly      ....  266 
1.30.  The  Thomas  Knee  Splint  viewed  from  above     .....  266 

131.  The  Bed  Splint  Variety  of  the  Thomas  Knee  S])lint     .  .  .  .266 

132.  Thomas  Kneo  Splint  applied           .......  267 

133.  The  CalUper  Sphnt 268 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


via.  rAGE 

134.  Thomas  Kneo  Splint  in  use            .......  268 

135.  Miller's  Incision  for  Excision  of  the  Knee-joint.            ....  272 

136.  Textor's  Incision  for  Excision  of  the  Knee-joint            ....  272 

137.  Kocher's  Incision  for  Excision  of  the  Knee-joint           ....  272 

138.  The  Vertical  Excision  SpUnt  used  after  Excision  of  the  Knee-joint             .  275 

139.  The  Crab  SpUnt  for  use  in  Tuberculous  Disease  of  the  Ankle-Joint  .            .  286 

140.  Kocher's  Incision  for  Excision  of  the  Ankle-Joint         ....  287 

141.  Incisions  for  Excision  of  the  Anterior  Tarsus      .....  293 

142.  Incision  for  Excision  of  the  Mid-Tarsus   ......  293 

143.  Incision  for  Excision  of  the  Os  Calcis       ......  294 

144.  Incision  for  Excision  of  the  Astragalus    ......  294 

145.  Multiple  Tuberculous  Dactylitis  with  Abscess  and  Sinus  Formation             .  298 

146.  Comparative  shortening  of  a  Finger  as  a  result  of  Tuberculous  Disease  of  the 

Metacarpal              .........  299 

147.  Tuberculous  Disease  affecting  the  Phalanges  and  the  Metacarpals     .            .  299 

148.  Healed  Tuberculous  Disease  of  the  Metacarpal  with  resulting  shortening  of 

the  Finger 300 

149.  Aluminium  Splint  appUed  for  Tuberculous  Disease  of  the  Metacar23a!s         .  300 

150.  Incisions  for  Excision  of  the  Metacarpals  and  the  Phalanges              .           .  301 

151.  Tuberculous  Disease  of  the  Right  Shoulder-Joint  with  Sinus  Formation      .  305 

152.  Incision  for  Excision  of  the  Shoulder  by  the  Anterior  Route             .           .  309 

153.  Advanced  Disease  of  the  Elbow-Joint  and  lower  end  of  Humerus     .           .  313 

154.  The  Halter  Sling  for  use  in  Tuberculous  Disease  of  the  Elbow-Joint            .  315 

155.  Kocher's  Incision  for  Excision  of  the  Elbow-Joint         ....  317 

156.  Tuberculous  Disease  of  tlie  Wrist-Joint  with  characteristic  swelhng  on  the 

Dorsum .  .  .320 

157.  Tuberculous  Disease  of  the  Wrist-Joint   ......  320 

158.  Jones's  SpUnt  for  the  Treatment  of  Tuberculous  Wrist  Disease         .            .  321 

159.  Tuberculous  Disease  of  the  Frontal  Bone  with  Abscess  Formation    .            .  328 

160.  Tuberculous  Disease  of  the  Ramus  of  the  Lef*JjOwer  Jaw     .           .            .  330 

161.  Tuberculous  Disease  of  the  Left  Malar  Bone      .....  332 

162.  Tuberculous  Disease  of  both  Malar  Bones           .....  332 

163.  Tuberculous  Disease  of  Right  Lower  Jaw  and  Left  Malar  Bone         .           .  333 

164.  Central  Tuberculous  Disease  of  the  Patella         .....  334 


PAET  I.-GENEEAL 


ETIOLOGY 

The  actual  causation  factor  in  tuberculous  disease  as  it  affects  the  bones 
and  the  joints  is  the  tubercle  bacillus  ;  but  such  a  simple  statement  is  by 
no  means  a  dismissal  of  the  matter,  because  bound  up  with  it  there  are 
other  factors  which  are  important  in  their  occurrence,  and  unfortunately 
much  more  difficult  in  their  investigation  and  their  elucidation.  There  are 
three  of  these  related  problems  : 

(1)  Is  there  any  special  importance  in  the  identity  of  the  bacillus  ?  Is 
the  human  or  the  bovine  bacillus  more  commonly  at  fault  ? 

(2)  What  are  the  routes  which  the  organisms  follow  in  reaching  the 
bones  and  the  joints  ? 

(3)  Are  there  any  factors  which  predispose  certain  parts  to  infection 
by  the  tubercle  bacillus,  more  especially  the  relationship  of  injury  to  the 
later  development  of  the  disease  ? 

The  Type  of  Organism. — Pathologists  have  divided  the  tubercle 
bacillus  as  a  group  into  four  subdivisions — human,  bovine,  avian,  and  piscine. 
As  far  as  the  pathology  of  man  is  concerned  one  may  neglect  the  two  latter. 
Since  the  memorable  dictum  of  Koch  in  1897  endless  investigations  have 
been  carried  out  to  clear  up  the  inter-relationship  between  human  and 
bovine  infection,  and  the  dissimilarity  or  unity  of  the  two  organisms. 

One  may  say,,  probably  beyond  question,  that  the  human  and  the 
bovine  bacillus,  originally  a  common  stock,  have  each  acquired,  by 
reason  of  their  residential  environments,  definite  characteristics  which 
enable  the  observer  to  distinguish  tiie  one  from  the  otlier.  In  tuberculous 
diseases  of  hones  and  joints,  as  in  other  forms  of  tuberculosis,  careful 
investigations  have  been  made  to  demonstrate  the  relative  ])roportion  of 
disease  which  is  human  or  bovine  in  origin.  The  metiiod  of  difl'orentiating 
between  the  bacilli  is  tedious  and  prolonged,  but  it  is  necessary  to  give  a 
summary  of  the  technique  by  which  the  separation  is  carried  out. 

No  attempt  is  made  to  isolate  the  bacillus  by  direct  cultivation.  Guiuea- 
pigs  are  inoculated  with  the  diseased  material,  a  piece  of  tuberculous  bono  or 
synovial  membrane  bcini;  ini])lantf'(l  beneath  tlie  skin  of  the  Hank.  An  animal 
80  infected  is  peiinitted  to  live  for  foin-  or  si.x  weeks.  During  this  time  the 
condition  of  the  animal  is  noted  and  a  careful  weight-history  kept.  At  the  end 
of  the  period  tiic  animal  is  killed,  and  from  the  tuberculous  organs,  more  especi- 
ally the  glands  and  the  spleen,  cultures  are  made  upon  suitable  media.     E.xperi- 

3  1 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


ence  has  shown  that  plain  egg  medium  (Dorset)  ^  and  glycerin  egg  medium 
(Lubenau)  ^  are  the  most  suitable.  The  diseased  organ  is  rubbed  upon  the 
surface  of  the  culture  tube  with  a  sterile  spud.  Tubes  so  inoculated  are  sealed 
with  paraffin  to  prevent  evaporation,  and  to  diminish  the  possibility  of  infection 
by  moulds.  About  ten  days  after  inoculation  a  growth  is  usually  apparent. 
With  the  successful  growth  of  the  organism  in  pure  culture,  the  first  stage  of  the 
investigation  is  completed,  and  it  remains  to  decide  to  which  class  the  organism 
belongs.  To  solve  this  question  the  organism  is  submitted  to  a  series  of  tests. 
In  the  author's  original  investigation  a  series  of  five  different  tests  were  em- 
ployed :  (fl)  The  original  culture  test ;  (b)  The  morphological  test ;  (c)  The 
special  cultm'c  test ;    {d)  Theobald  Smith's  test ;    (e)  The  inoculation  test. 

(o)  Original  Culture  Test. — Smith '  noted  cultm-al  distinctions  between 
different  strains  of  tubercle  bacilli  when  they  were  grown  upon  blood  serum. 
Kavenal  *  described  similar  distinctions  upon  glycerin  agar,  and  Dorset  upon  egg 
medium.  The  British  Royal  Commission  ^  found  such  a  constant  distinction 
that  they  formulated  two  classes  :    a  eugonic,  or  readily  growing  class,  and  a 

dysgonic,  or  slowly  growing  class.  To  the 
first  the  great  majority  of  human  bacilli 
belong.  Bovine  bacilli  are  most  suitably 
described  under  the  second  heading.  This 
test  cannot  be  considered  absolute  because 
a  margin  of  error  exists  in  those  cases  which 
are  on  the  border  line  between  eugony  and 
dysgony,  but  it  is  useful  in  so  far  as  it  forms 
the  first  clue.  A  rapidly  growing  and  profuse 
culture  is  likely  to  be  human  in  type,  while 
a  weak  and  scanty  growth  is  in  all  proba- 
bility bovine. 

The  fallacies  of  the  test  have  been 
discussed  by  Rabinowitsch,^  Fibiger  and 
Jensen,^  Park  and  Krumwiede.® 

(b)  Morphological  Test. — At  one  time 
it  was  believed  that  structural  differ- 
ences between  the  strains  of  tubercle  bacilli 
might  prove  of  value  as  a  distinguishing  test.  The  Iiuman  bacillus  is  usually 
considered  to  be  slender,  regular  in  shape,  and  long,  while  the  bovine  bacillus 
is  squat  and  thick  (Kossel,  Weber,  and'Heuss).^  If  these  differences  were  con- 
stant the  test  might  be  a  valuable  one,  but  if  the  test  is  to  be  of  any  assist- 
ance the  bacilli  must  be  observed  in  an  early  and  original  culture  ;  prolonged 
residence  or  multiple  subculture  tends  to  produce  a  common  morphological 
mean.  Dorset  affirms  that  he  found  no  such  distinctive  features  between 
the  bacilli,  and  his  views  are  in  agreement  with  those  of  Wolbach  and  Ernst.^" 


Fig.  1. — The  ovigiual  cullme  te.st  :  The 
centre  tube  contains  a  human  bacillus, 
the  lateral  ones  contain  bovine  bacilli. 


1  M.  Dorset,  Am.  Med.,  1902,  iii.  55.5. 

^  C.  Lubenau,  Ilyg.  Rundschau,  1907,  .wii.  1455. 

'  T.  Smith,  Tr.  Ass.  Am.  Pliijs.,  1896,  xi.  75. 

*  M.  P.  Ravenal,  Univ.  Penii  Med.  Bull.,  1901-2,  xiv.  238. 

^  Royal  Commission  on  Tuberculosis,  Second  Interim  Report,  1907,  Pt.  I.,  23. 

«  L.  Rabinowitsch,  Arb.  a.  d.  path.  Inst,  zu  Berlin,  1906,  365. 

'  J.  Fibiger  and  C.  O.  .Jensen,  Bert.  Bin.  Wchnschr.,  1908,  xlv.  1876. 

*  W.  H.  Park  and  C.  Krumwiode  and  othor.s.  Studies  from  the  Research  Laboratory  oj  the 
Department  of  Health  of  the  City  of  New  York;  1908-10,  iv.  7. 

»  H.  Ko.s.scl,  A.  Weber,  and  Heu.s.s,  Tubcrk.  Arb.  a.  d.  k.  Osndhtsamie,  1904,  i.  1  ;    1905, 
ii.  1. 

i»  S.  B.  Wulbaeh  and  H.  C.  Ernst,  Journ.  Med.  Research,  1903-4,  x.  313. 


ETIOLOGY  5 

If  the  observer  is  careful  to  examine  the  early  and  original  culture,  the 
test  is  useful  as  a  suggestive  one. 

In  tubercle  bacilli  there  has  been  frequently  noted  the  presence  of  deeply- 
staining,  spore-like  bodies,  and  they  have  been  described  in  considerable  detail 
by  Coppen- Jones. '^  These  are  found  occurring  most  constantly  in  bacilli  from 
a  human  source,  and  their  presence  is  best  demonstrated  by  the  use  of  Much's 
stain. 

(c)  SjKcial  Culture  Test. — The  presence  of  glycerin  has  a  restraining  effect 
on  the  growth  of  the  bovine  bacillus  (Moeller),^  but  it  has  rather  a  stimulating 
effect  on  the  growth  of  the  human  bacillus.  The  glycerin  is  incorporated 
in  such  a  medium  as  glycerin  egg.  This  test  must  be  employed  from  primary 
cultures,  as  the  vegetative  capacities  of  the  bovine  bacillus  increase  on  frec^uent 
subculturing.  One  may  say  that  cultures  growing  luxuriantly  from  the  beginning 
upon  glycerin  egg  medium  are  of  the  human  type,  while  cultures  growing 
sparsely  or  even  not  at  all  on  this  medium  are  bovine  in  character. 

(d)  Theobald  Smith's  Test.^ — By  inoculating  glycerin  bouillon  medium  it 
is  possible  to  produce  upon  its  surface  a  pellicular  growth  of  tubercle.  The 
growth  is  easily  started  by  loading  a  tiny  cork  raft  with  the  culture  mass,  and 
floating  it  upon  the  medium.  From  this  nucleus  a  growth  soon  extends  over 
the  surface.  The  rate  of  growth  of  the  pellicle  is  an  indication  of  the  type  of 
the  bacUlus,  but  the  development  of  the  pellicle  gives  rise  to  a  change  in  the 
reaction  of  the  medium  which  is  valuable  as  a  distinguishing  test.  Before  the 
medium  is  inoculated  its  acidity  is  carefully  estimated  by  titration  and  made 
up  to  a  standard  reaction  by  adding  0-05  N/.5  of  hydrochloric  acid  to  glycerin 
bouillon  neutral  to  litmus. 

As  the  organism  grows  and  the  pellicle  develops,  in  the  human  case  the 
acidity  increases,  while  in  the  instance  of  the  bovine  bacUIus  the  acidity  for  a 
time  diminishes,  and  the  medium  may  even  become  alkaline.  It  is  recognised 
that  the  reaction  actually  depends  on  the  different  rates  of  growth  of  the 
two  varieties  of  bacilli. 

From  a  medium  so  inoculated  five  cubic  centimetres  of  fluid  are  removed 
every  ten  days,  and  the  reaction  estimated  by  titration.  Smith  recommends 
that  the  medium  be  titrated  when  hot ;  before  titration  it  ought  to  be  diluted 
to  10  per  cent  of  its  usual  strength.  The  titration  results  may  be  graphically 
demonstrated  by  plotting  them  upon  a  curve. 

(e)  Inoculation  'Test. — It  has  long  been  noted  that  tuberculous  material 
from  different  sources  varied  in  its  etTects  on  bovines  and  on  man.  Villemin  ■* 
observed  tlie  fact,  and  Smith  may  be  said  to  have  fornmlated  it  into  a  test  ; 
he  published  articles  on  the  subject  in  1896  ^  and  1898.^ 

The  test  may  be  stated  as  follows  :  If  a  rabbit  with  an  average  weight  of 
2000  grams  is  inoculated  with  a  small  known  quantity  of  tubercle  bacilli  it  will 
react  to  tln^  inoculation  in  various  way.s.  If  a  human  bacillus  is  employed,  tiie 
resulting  lesions  are  small  and  few  in  numljer,  and  after  a  time  they  show  a 
tendency  to  undergo  retrogression.  If  (h^ath  occurs,  it  is  usually  more  than  six 
months  after  the  original  inoculation,  and  frequently  tuberculosis  is  not  the 
cause  of  death.  If  a  bovine  bacillus  is  used,  an  acute  disseminated  tuberculosis 
develops  which  is  rapidly  fatal. 

'  A.  ('(i|i|ioii-Ji)ncs,  Centralbl.  j.  Balcteriol.,  18!t.'),  xiii.  70. 

■'  A.  .Mueller,  Deutsche  med.   Wrhnnchr.,  l'J02,  .\xvii.  7 IS. 

'  T.  Smith,  .fourti.  Med.  Reaearch,  l!)04-.5,  xiii.  40'). 

*  ■!.  A.  \'illeinin,  Ulitdes  experimtiitates  «ur  la  luberciiluw,  Paris,  1808,  ii.  237. 

'  'I'.  Smilli,  Journ.  Kxper.  Med.,  1898,  iii.  451. 

^  Loc.  nup,  rit. 


6  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

The  quantity  of  tubercle  bacilli  introduced  varies  according  to  tlie  method 
of  injection.  0-01  mgni.  is  a  suitable  amount  for  intravenous  inoculation  ;  10 
mgms.  may  be  given  subcutaneously. 

Such  bacteriological  investigations  have  been  carried  out  by  the  British 
Royal  Commission  (14  cases)/  Park  and  Krumwiede  (71  cases), ^  Buckhardt 
(29  cases),^  Kossel,  Weber,  and  Heuss  (36  cases),*  and  the  author  (70  cases).^ 
The  results  of  these  different  enc|uiries  show  a  marked  divergence  of  results. 
In  Kossel,  Weber,  and  Heuss's  series  only  one  case — a  percentage  of  2-7 — 
was  due  to  a  bovine  infection,  while  in  the  author's  series  of  70  cases  a 
proportion  of  60  per  cent  owed  their  origin  to  infection  with  the  bovine 
bacillus.  But  these  results,  so  apparently  irreconcilable,  can  be  perfectly 
understood.  A  large  proportion  of  bovine  infection  is  closely  related  to 
two  other  facts — an  infected  milk  supply  and  a  young  age  incidence. 

Let  us  take  the  facts  in  their  natural  secpence.  Until  the  age  of  twelve 
years  milk  forms  a  staple  article  of  diet  among  the  large  majority  of  our 
population.  If  such  milk  be  infected  with  the  bacillus  of  bovine  tuberculosis, 
as  it  most  probably  will  be  if  it  is  obtained  from  a  tuberculous  cow,  there 
will  in  all  probability  result  from  its  ingestion  tuberculous  disease  of  the 
lymphatic  glands,  cervical  or  mesenteric.  From  this  primary  source  the 
bones  and  joints  become  infected,  and  in  such  lesions  bovine  tubercle  bacilli 
can  be  demonstrated.  Therefore  a  large  proportion  of  infection,  due  to  the 
bovine  bacillus,  at  once  suggests  to  one's  mind  that  the  real  source  of  the 
trouble  lies  in  a  contaminated  milk  supply. 

The  considerable  proportion  of  bovine  infection  is,  in  fact,  explanatory 
of  a  fact  which  is  discussed  elsewhere,  namely,  the  relatively  great  occur- 
rence of  osseous  tuberculosis  in  the  periods  of  infancy  and  youth. 

Channels  of  Entry  of  the  Bacilli  into  the  Body.^One  may 
neglect  as  a  most  unlikely  possibility  the  question  of  a  pre-natal  infection 
by  tubercle.  In  post-natal  existence  there  are  two  obvious  channels  by 
which  the  disease  gains  admission — the  respiratory  tract  and  the  ahmentary 
tract.  Both  of  these  have  had  their  chamj)ions,  men  who  have  urged  each 
in  its  individual  importance.  Calmette  ^  and  von  Behring  "  have  contended 
that  in  the  ahmentary  tract  one  has  the  medium  through  which  the  disease 
most  commonly  enters.  Hamburger,  Jacobi,  and  Holt  have  championed 
the  claim  of  the  aerogenous  route.*  There  is,  however,  no  necessity  to 
dogmatise.  Both  routes  are  available,  and  at  varying  periods  of  life  the 
relative  importance  of  each  differs.  In  children  surgical  tuberculosis  is 
usually  the  primary  manifestation,  and  if  pulmonary  disease  appears  it  is 
^     as  a  rule  a  secondary  infection.     In  adult  life  the  process  is  reversed,  the 

*  Royal  Commission  on  Tuberculosis,  Final  Report,  1911,  Ft.  I.,  13. 
^  Loc.  sup.  cit. 
3  H.  Buckhardt,  Deutsche  Ztsch:  f.  Cliir.,  1910,  cvi.  1. 

*  Loc.  sup.  cit. 

^  J.  Fraser,  Journ.  of  Expt.  Med.,  xvi.,  No.'4,  1902,  p.  432. 
"  C.  Calmette,  Ann.  de  VinM.  Pasteur,  Paris,  1905,  tome  xix.  p.  GUI. 
'  L.  V.  Behring,  Deutsche  vied.  Wchnschr.,  Leipzig,  190.3,  S  fJ89. 
'  Tliese  contentions  have  arisen  more  especially  in  deciding  the  route  of   infection  in 

phthisis. 


ETIOLOGY  7 

lungs  are  most  frequently  the  first  to  suffer,  and  from  tliem  infection  extends 
to  the  bones  and  glands.  And  as  the  sequences  differ,  so  probably  do  the 
channels  of  infection,  the  alimentar}-  system  in  youth,  the  respiratory  system 
in  later  life.  In  urging  the  importance  of  the  alimentary  infection,  one 
must  bear  in  mind  that  the  apparent  resistance  of  the  mesenteric  glands 
— the  first  to  show  signs  in  an  ingestion  infection — varies  considerably  in 
early  and  in  later  life.  The  mesenteric  glands  of  a  child  are  more  readily 
infected  than  those  of  an  adult.  Through  the  latter  tubercle  bacilli  may 
enter  the  body,  and  leave  no  sign  of  their  passage  (Guerin).  Therefore 
one  must  not  consider  the  alimentary  routes  of  infection  a  monopoly  of 
youth. 

There  are  other  less  common  means  of  entrance — the  tonsils  and  the 
mucous  membrane  of  the  pharynx,  the  skin,  the  genito-urinary  passages, 
and  the  teeth.  We  have  frequently  noted  that  tuberculous  disease  of  the 
submaxillary  group  of  lymphatic  glands  owed  their  infection  to  the  presence 
of  tubercle  bacilli  in  the  pulp  of  decayed  teeth. 

Tubby  ^  believes  that  tuberculous  dactylitis  sometunes  owes  its  occur- 
rence to  infection  of  overlying  skin  wounds  with  tubercle,  the  bacilli  being 
obtained  by  crawling  upon  dirty  floors. 

Routes  of  Infection  of  the  Bones  and  the  Joints. — One  may 
assume  that  direct  infection  of  a  bono  or  joint  from  without  is  rare  in  its 
occurrence,  and  negligible  as  an  etiological  factor.  There  therefore  remain 
the  more  indirect  routes  of  the  blood  stream  and  the  lymph  streams.  These 
are  the  questions  to  be  answered,  Does  one  or  do  both  of  these  routes 
provide  the  paths  of  infection  ?  and,  further.  Are  the  bones  and  the  joints 
equally  liable  to  infection,  or  do  they  stand  in  relation  to  one  another  as 
primary  and  secondary  infections  ? 

It  might  be  well  briefly  to  epitomise  the  more  important  work  which 
has  been  done  to  aid  in  the  elucidation  of  these  questions. 

Schiiller  ^  in  1880  described  how  he  iiijectcil  tiiherculinis  niateiial.  sputum, 
glands,  etc.,  tlirougli  a  tracheotomy  opening  into  the  lung.s  of  dogs  and  rabbits, 
coincidentally  injui-ing  one  of  the  knee-joints  of  the  infected  animal  ;  he  suc- 
ceeded in  producing  generalised  tuberculosis  and  a  tuberculous  synovitis  of  the 
injured  joint. 

Miiller  '  in  1886  injected  the  nutrient  Ixme  vessels  of  goats  ;  apparently 
there  resulted  a  multiple  tuberculous  osteomyelitis  of  the  bone  .su])])lied  by  the 
infected  blood-vessel  with  accompanying  infection  of  the  neighbouring  joints. 
Miiller  quoted  his  results  in  demonstration  of  the  hematogenous  infection  of 
osseous  tubercle. 

In  1891  Krause  *  published  the  results  of  his  experimental  work,  lie 
injected  pure  cultures  of  tubercle  bacilli  subcutaneously  into  guinea-pigs  and 
intravenously  into  rabbits.     Directly  before  or  immediately  after  the  inocula- 

'  Tulil)\',  Tuberculous  Disease  uf  the  Hones  and  Joints,  ii.  |>.  (i. 

'  M.  .Scliiillfr,  ExpcriinenteUe  unti  liisloloijisclie  Viitersuchunijcn  iiber  die  Entstehunij  und 
Uraaclicn  der  shrophulOsen  und  tubcrkuhisen  Oclenklciden,  Stuttgart,  1880. 
»  W.  Miiller,  Centmtbl.  f.  Cliir.,  I8HG,  xili.  2X1 

*  v.  Kiause,  Die  Tubcrkulose  der  Knuchen  und  Gclcnkcn.  Li'ip/.ii:.  1891.  80-102. 

1  a 


8  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

tion,  or  after  a  variable  space  of  time,  a  joint  was  injured  or  a  bone  broken.  In 
no  case  was  there  evidence  of  tubercle  at  the  site  of  fracture,  but  in  the  instance 
of  the  joints  many  of  them  became  tuberculous, — fifteen  joints  out  of  forty-four 
in  guinea-pigs,  and  fourteen  out  of  twenty-eight  in  rabbits.  The  uninjured 
joints  with  one  exception  remained  healthy. 

A  number  of  experiments  upon  rabbits  were  carried  out  by  Benda  ^  in 
1899.  He  intimated  his  belief  that  the  original  lesion  was  an  actual  focus  of 
tuberculous  disease  in  the  tunica  interna  of  the  blood-vessel,  and  from  such  a 
focus  there  was  a  continuous  liberation  of  bacilli  into  the  blood  stream. 

Lannelongue  and  Achard  ^  (1899)  found  that  it  was  b}'  no  means  an  easy 
matter  to  trace  experimentally  the  source  and  origin  of  osseous  or  joint  tubercle. 
They  inoculated  guinea-pigs  in  various  ways,  and  directly  afterwards  or  some 
time  later  they  produced  local  injuries  of  the  bones  or  joints,  but  they  failed  to 
produce  tuberculous  lesions. 

With  a  view  to  investigating  the  haemic  routes  of  infection,  Friedrich  ^ 
in  1899  introduced  tuberculous  cultures  of  low  virulence  into  the  left  ventricle 
of  rabbits.  He  succeeded  in  producing  tuberculous  joint  affections.  Certain 
of  the  joints  had  been  previously  injured,  but  he  found  that  those  subjected  to 
traumatism  were  less  likely  to  become  infected  than  the  apparently  healthy 
ones. 

What  practically  amounted  to  the  antithesis  of  this  view  was  expressed 
by  Pietrzikowski  *  (1903).     According  to  this  view  20  per  cent  of  all  tuber- 
culous affections  of  bones  and  joints  were  connected  with  some  forms  of  injury  ; 
this  rarely  amounted  to  a  fracture  or  dislocation,  but  usually  an  injury  of  lesser  . 
degree,  such  as  a  sprain  or  bruise. 

In  190-1  Salvia  ^  injected  virulent  cultures  of  tubercle  intravenously  into 
rabbits  ;  simultaneously  various  parts  of  the  body  were  subjected  to  trauma- 
tism. He  found  that  in  the  flat  bones  the  violence  practically  always  decided 
the  localisation  of  tubercle  ;  no  localisation  could  be  obtained  in  the  long  bones 
of  the  limb,  but  slight  injuries  to  the  parts  sometimes  resulted  in  tuberculous 
disease. 

Out  of  such  a  mass  of  experimental  evidence  it  is  difficult  to  unravel 
certainties  ;  there  are  so  many  apparent  contradictions,  but  there  are  two 
facts  which  are  clear,  and  they  are  :  (1)  That  it  is  difficult  to  reproduce 
experimentally  tuberculous  lesions  of  the  bones  and  the  joints  ;  (2)  That 
trauma  as  a  localising  factor  is  slight  in  degree  rather  than  severe. 

The  possibility  of  the  lymph  stream  being  an  important  route  of 
infection  one  may  dismiss  ;  neither  the  bones  nor  the  joints  bear  a  close 
connection  with  the  lymphatic  system,  and  many  authorities  deny  their 
presence  in  either  structure.  And  further  from  the  naked-eye  and  the 
microscopic  appearance  of  the  lesion  in  both  situations  there  can  be  no 
shadow  of  a  doubt  that  the  blood  stream  is  the  main,  in  fact  one  would 
say  the  only  route  of  infection.  But  there  follows  a  que.stion  which  is 
much  more  difficult  in  its  decision,  Are  bones  and  joints  ec^ually  susceptible 
to  infection,  or  is  the  one  more  readily  infected  than  the  other  ? 

1  K.  Benda,   Verliaiidl.  d.  deiUscIi.  Oesellsch-.  f.  C'liir.,  1899,  .xxviii.  48. 

-  O.  M.  Lannelongue  and  C.  Achard.  Compt.  rend.  Acad,  des  He,  1899,  cxxviii.  1075. 

«  P.  L.  Friedrich.^ Deutsche  Zlsckr.  J.  Chir.,  1899,  liii.  512. 

«  E.  Pietrzikowski,  Ztschr.  f.  Heillc,  1903,  xxiv.  187. 

^  E.  Salvia,  PolicUnico,  1904,  xi.,  sez.  chir.,  367. 


ETIOLOGY  9 

As  far  as  the  relative  percentage  of  occurrence  is  concerned,  joints  are 
to  a  slight  degree  more  commonly  affected  than  bones.  During  a  period  of 
ten  years  there  were  admitted  to  the  wards  of  the  Edinburgh  Sick  Children's 
Hospital  464  cases  of  tuberculous  joint  disease,  while  the  number  of  cases 
of  pure  bone  tubercle  amounted  to  353  cases.  Practically  the  only  way 
in  which  such  a  question  can  be  decided  is  by  experimental  research,  and  in 
such  an  investigation  one  must  remember  that  one  is  not  reproducing 
exactly  the  condition  one  finds  clinically.  The  result  of  the  most  recent 
experimental  work  may  be  summed  up  in  the  following  conclusions  : 

(1)  The  joints  are  more  susceptible  to  infection  by  tuberculous  disease 
than  the  bones. 

(2)  The  joints  are  infected  through  the  medium  of  the  blood  stream. 
Predisposition  by  reason  of  Injury.— Every  clinician  must  have 

noted  the  regularity  with  which  one  obtains  in  tuberculous  disease  of  a 
bone  or  joint,  the  history  of  a  previous  traumatism.  If  such  is  not  im- 
mediately forthcoming,  a  little  detailed  cross-examination  rarely  fails  to 
extract  it.  There  can,  however,  be  not  the  slightest  doubt  that  in  a  certain 
number  of  cases  traumatism  does  play  a  part  in  the  etiology.  The  trauma 
is  not  a  severe  one,  it  may  be  so  minor  as  to  have  escaped  the  patient's 
attention.  The  explanation  of  the  minor  degree  of  injury  lies  probably  in 
this  fact.  An  injury  of  some  severity  produces  such  a  state  of  tissue  reaction 
that  the  lodged  organism  is  neutralised  and  destroyed.  When  the  trauma 
is  slight  no  reaction  follows,  but  instead  a  small  effusion  of  blood  and 
lymph,  a  condition  of  affairs  which,  by  a  temporary  local  arrest  of  blood 
flow,  favours  a  stagnation  of  the  organism  and  the  development  of  a  definite 
pathological  lesion. 

There  is  another  aspect  to  the  influence  which  injury  has  upon  the 
development  of  a  tuberculous  lesion.  Not  only  may  it  favour  its  original 
deposit,  but  when  it  has  developed  it  may  very  materially  alter  its 
further  characteristics,  and  from  this  point  of  view  the  influence  of  trauma- 
tism is  probably  under-rated  (Wilson). ^  A  form  of  disease  which  has  hitherto 
remained  defined  and  encapsulated  may  become,  after  the  receipt  of  an 
injury,  an  actively-spreading  and  infiltrating  tubercle  ;  and  on  a  larger 
scale,  disease  previously  limited  to  the  articular  extremity  of  a  bone,  may 
be  suddenly  complicated  by  a  wholesale  infection  of  the  near-lying  joint,  or 
of  the  surrounding  soft  parts. 

These  relations  of  traumatism  to  the  spread  of  the  disease  are  of  much 
greater  importance  in  their  practical  bearing  than  any  influence  they  may 
have  upon  the  original  development  of  the  disease. 

Predisposition  by  Heredity.— Above  twenty  cases  of  apparent  true 
congenital  tuberculosis  have  been  reported,  and  liaumgarten  ^  believes  that 
the  virus  is  actually  transmitted  to  the  subject  during  intra  -  uterine 
development.     Baumgarten   suggests   that   the   developing  tissues   retard 

'  H.  A.  Wilson  ami  K.  C.  Rosenberger,  "  Tho  Relation  of  Trauinii  to  Bone  'ruborculosis,' 
New  Yoric  M.J.,  I'JKi,  xcvii.  122:j-1225. 

'  IJannigarten,  Deutsche  med.  Wchnechr.,  Leipzig,  1909,  S  1729. 

16 


10  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

the  growth  of  the  infecting  organism,  which,  lying  latent,  produces  active 
tuberculosis  in  later  post-natal  life.  This  is  a  view  which  has  aroused  strong 
opposition.  It  would  probablj'  be  more  correct  to  say  that  the  presence  of 
tuberculosis  in  the  parents  leads  to  a  weakening  in  the  developing  embryonic 
and  foetal  tissues,  with  a  resulting  predisposition  to  disease  in  any  form. 
A  special  source  of  infection  to  tubercle  exists  in  the  person  of  the  tuberculous 
parent,  and  the  infection  of  the  offspring  is  the  all  too  frequent  result. 

The  question  of  germinal  infection  is  still  very  largely  one  of  speculation. 

Predisposition  by  General  Causes.— There  are  many  other  factors 
which  predispose  to  disease.  The  exanthemata  are  important.  Their 
ravages  are  followed  by  a  lowering  of  vitality  and  a  surrender  to  the  disease, 
and  so  it  is  with  influenza.  Then  there  are  the  questions  of  feeding,  be  it 
bad,  insufiicient,  or  improper,  and  unhygienic  surroundings,  want  of  fresh 
air  and  sunlight. 

The  Frequency  of  Affection  of  the  various  Bones. — During  a 
period  of  ten  years  there  has  come  under  treatment  in  the  wards  of  the 
Edinburgh  Sick  Children's  Hospital  a  total  of  353  cases  of  bone  tuberculosis 
(entirely  exclusive  of  joint  disease  and  spine  disease). 

The  incidence  of  individual  bones  is  represented  in  the  following  table  : 


Bone. 

Number. 

Percentage. 

Bones  of  skull,  mastoid  and  malar  . 

Si 

23 

Metatarsus,  tarsus,  and  jihalanges   . 

80 

23 

Tibia 

39 

10 

Ulna 

26 

7-3 

Metacarpus,  carpus,  and  phalanges. 

26 

7-3 

Femur           

24 

7 

Humerus 

21 

a 

Lower  jaw 

18 

5-4 

Rib 

14 

4 

Radius 

14 

4 

Fibula 

10 

3 

The  high  percentage  of  disease  affecting  the  skull  bones  is  largely  due 
to  tuberculous  conditions  of  the  mastoid.  Excluding  thesC;  the  short  bones 
are  the  most  frequently  affected,  and  those  of  the  foot  in  a  greater  degree 
than  those  of  the  hand.  Of  the  long  bones,  the  tibia  and  the  uhia  are  most 
frequently  involved. 

Vertebral  disease  has  been  purposely  excluded.  It  of  course  forms  by 
far  the  greater  proportion  of  bone  tuberculosis,  yet  the  peculiar  structure 
of  the  bone  and  the  relation  of  the  intervertebral  discs  lead  us  to  consider 
it  in  a  separate  and  distinct  class  (see  p.  111). 

The  Frequency  of  Affections  of  the  various  Joints.— During  the 
period  above  mentioned  46-1  cases  of  joint  disease  were  admitted  for  treat- 
ment.    The  relative  frequency  was  as  follows  : 

[Table 


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I'LATK   I. 

Till'  iirniiia]  jitiatniny  o!"  tin*  cinl  oi'  u  Ion;,'  Ipoiu-,  showing  tlie  avtiriiliir  surface,  the  ejiiitliysis,  the 
p'seal  cart ila;;*',  ami  tlif  tiietapliysis.  A,  'I'lic  articular  cinl  of  tlic  liunierus.  c,  Tlie  c|>ii>liyscal 
ge  with  (-pijihysis  uhovr  and  irictaphysis  lichiw.  (K  A  Volkmaun's  canal  i»ieroing  the  cortical  bone, 
lig  Willi  it  a  blood-vessel. 


THE  PATHOLOGY  OF  TUBERCULOSIS  OF  BONE 


11 


Joint. 

Number. 

Percentage. 

Hip     . 

171 

37 

Knee  . 

133 

27 

Elbow 

•   1              " 

18 

Ankle 

72 

15-5 

Wrist 

8 

2 

Shoulder    . 

3 

5 

The  proportions  are  in  keeping  with  those  published  elsewhere.  The 
hip  is  the  joint  most  frequently  affected  ;  the  knee  is  sUghtly  less  common. 
The  elbow  and  the  ankle  are  very  similar  in  the  percentage  of  their  infection. 


THE  PATHOLOGY  OF  TUBERCULOSIS  OF  BONE 


Normal  Anatomy  of  Bone 

Bone  is  really  a  type  of  connective  tissue  in  which  the  ground-work  has 
become  impregnated  mth  salts  of  lime,  and  a  comprehension  of  this  fact 
simplifies  considerably  the  apparent  complexity  of  its  structure.  The 
connective  tissue  is  a  variety  of  areolar  tissue,  and  the  earthy  salts  are  chiefly 
lihosphate  of  lime. 

Bone  is  said  to  be  compact  or  cancellous  according  to  the  degree  of 
interspaces  in  its  structure.  As  a  rule  the  outer  layers  of  a  bone  are  compact 
and  the  deeper  tissues  cancellous.     The  marrow  occupies  the  interspaces. 

Each  bone  is  built  upon  definite  architectural  lines,  and,  more  especially 
in  the  long  bones  and  short  long  bones,  a  knowledge  of  the  scheme  of  archi- 
tecture is  essential  to  an  understanding  of  the  pathology.  The  scheme 
is  most  complete,  and  is  seen  to  its  best  advantage  in  any  of  the  long  bones. 
The  greater  portion  of  the  length  is  formed  by  the  shaft.  At  the  end  of  the 
shaft  there  is  the  epiphyseal  cartilage,  and  that  portion  of  the  shaft  which 
immediately  abuts  upon  tlie  cartilage  is  given  a  special  name,  that  of  the 
metaphysis. 

On  the  distal  side  of  the  epiphyseal  cartilage  there  lies  the  epiphysis, 
and  the  free  surface  of  the  epiphysis  is  usually  covered  with  hyaline  articular 
cartilage.  In  all  the  long  bones  an  arrangement  such  as  is  described  occurs 
at  both  extremities  of  tlie  sluift.  In  the  siiort  long  bones,  where  there  is  only 
a  single  epiphysis,  one  end  has  such  an  arrangement,  the  other  extends 
directly  to  the  articular  cartilage. 

There  are  no  special  features  in  the  formation  of  the  flat  and  the  short 
bones. 

Blood  Supply  of  Bones 

Lexer  ^  traced  the  course  of  blood-vessels  in  bone  by  stereoscopic  X- 
ray  photographs.     The  vessels  were  injected  with  a  solution  of  mercury 
'  Lo.xor,  Unlerauchunj/en  ilbcr  Knocheimrterien,  1904,  Lexer,  Tuliga,  and  Turk. 


12  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

in  oil  of  turpentine,  and  the  photograplis  were  taken  with  the  periosteum 
and  attached  ligaments  in  situ.  Under  these  conditions,  while  the  periosteal 
vessels  were  clearly  visible,  the  intraosseal  branches  were  indistinct  and 
blurred  ;  these  latter  were  shown  in  a  second  series  of  photographs  taken 
after  removal  of  the  periosteum. 

The  vascular  arrangements  differ  in  the  long  tubular  bones,  the  short 
long  bones,  the  flat  bones,  the  vertebrae  and  ribs,  and  such  a  composite  bone 
as  the  ilium. 

Long"  Tubular  Bones. — About  the  centre  of  the  shaft  the  nutrient 
vessel  enters  the  bone.  Just  before  its  entry  it  becomes  tortuous,  an  arrange- 
ment which  has  a  double  purpose.  It  partly  permits  of  an  elongation  of  the 
vessel,  according  to  certain  positions  of  the  part,  and  further  it  reduces 
the  pressure  before  the  blood  stream  bifurcates. 

Having  entered  the  bone  the  vessel  divides  almost  immediately  into 
two  divisions,  which  run  in  exactly  opposite  directions  towards  the  extremi- 
ties of  the  bone.  These  vessels  are  the  nutritise  ;  they  do  not  long  remain 
single,  they  rapidly  subdivide  and  extend  to  the  epiphyseal  cartilage  in  a 
parallel  and  leash-like  arrangement. 

A  second  series  of  vessels  pass  into  the  bone  immediately  on  the 
diaphyseal  side  of  the  epiphyseal  cartilage.  They  are  usually  derived  from 
the  anastomosis  around  a  neighbouring  joint,  and  from  their  relationship 
to  the  epiphyseal  cartilage  they  are  called  the  juxta-epiphyseal  vessels.  They 
anastomose  with  the  termination  of  the  nutrient  vessels  in  the  metaphysis. 

The  third  group  is  formed  by  the  epiphyseal  vessels,  they  also  are 
derived  from  the  anastomosis  around  the  joint,  they  perforate  the  epiphysis 
and  the  epiphyseal  cartilage,  and  their  termination  is  an  anastomosis  in  the 
metaphysis.  The  scheme  is  completed  by  a  complex  anastomosis  beneath 
the  periosteum.  The  ultimate  anastomosis  in  the  metaphysis  of  three 
different  groups  of  vessels  is  the  point  of  greatest  practical  importance. 

The  Short  Long  Bones. — The  scheme  is  very  similar  to  that  in  the 
tubular  bones,  but  the  presence  of  usually  only  a  single  epiphysis  constitutes 
an  important  difference.  The  nutrient  vessel  enters  the  shaft  about  its 
centre,  but  there  is  a  point  of  distinction  in  so  far  as  it  breaks  up  almost 
immediately  into  a  plexus :  there  are  no  long  parallel  nutritise.  At  that 
extremity  of  the  bone  which  possesses  an  epiphysis  the  vascular  arrange- 
ments are  exactly  similar  to  those  in  the  tubular  bones.  At  the  other 
extremity  the  juxta-epiphyseal  vessels  are  necessarily  absent,  and  only  those 
analogous  to  the  epiphyseal  vessels  exist. 

Flat  Bones  and  Vertebrae. — Each  of  the  flat  bones  is  supplied  by 
a  nutrient  vessel,  which  enters  about  the  centre  of  the  bone,  and  rapidly 
subdivides ;  the  periosteal  vessels  are  of  greater  importance  than  in  the 
long  bones.  The  vertebrae  have  a  distinctive  distribution — two  large  and 
parallel  vessels  enter  the  body  from  behind,  and  reaching  the  centre  of 
the  body,  they  are  joined  by  a  series  of  small  vessels,  running  inwards 
from  the  front.  Corresponding  to  the  juxta-epiphyseal  vessels  of  the  long 
bones  there  are  vessels  entering  at  the  attachment  of  the  transverse  process 


B 


rrATE  II— The  Scheme  of  the  Abtehial  Blood  Hvvvlx  of  Bones. 

A.  T..e  ,,.00..  s.pp,y  or  ..e  ,c.«  ^>---^,Zt:i:;Zl^T-J:^l  ai-.^'^i" 
tlie  OS  iiinoiniu«tuni  aiul  the  nbs.     t^,    i"i-   "i"""     "i  I '.' 
arnini;./iiiciit  In  tli.'  At.iis.     (Alter  Lexer.) 


THE  PATHOLOGY  OF  TUBERCULOSIS  OF  BONE     13 

to  tlie  body.  The  vascular  arrangements  are  similar  in  all  the  vertebrae, 
^vith  the  exception  of  the  atlas  :  it,  not  possessing  a  body,  derives  its  blood 
supply  from  two  large  lateral  vessels. 

Ribs. — Each  rib  is  supplied  by  a  nutrient  vessel,  which  enters  the 
bone  from  its  outer  surface,  just  beyond  the  tubercle,  and  runs  forwards 
inside  the  bone  as  far  as  the  costal  cartilage,  where  it  is  joined  by  vessels 
from  the  perichondrium. 

The  Pelvis. — On  account  of  the  composite  formation  the  vascular 
distribution  in  the  pelvic  bones  is  peculiar.  The  main  nutrient  vessel  enters 
the  ilium  obliquely  from  behind  through  a  large-sized  foramen  close  to  the 
great  sacrosciatic  notch  ;  it  breaks  up  into  fine  radial  twigs  which  extend 
to  the  crest  of  the  acetabulum.  A  second  vessel  enters  at  the  sacro-iliac 
synchondrosis  and  distributes  branches  upwards.  The  periosteum  is 
independently  well  supplied  with  blood. 

Microscopic  Anatomy  of  Bone 

Lamellae  or  strands  of  connective  tissue  in  a  calcified  ground  substance 
constitute  the  framework  of  a  bone.  Between  the  lamellae  are  the  inter- 
spaces which  the  marrow  occupies,  and  scattered  through  the  substance 
of  the  lamellae  there  are  the  branching  bone  corpuscles,  each  occupying  its 
space  or  lacuna.  The  branching  processes  of  the  bone  corpuscles  extend  into 
the  surrounding  bone,  along  the  minute  channels  spoken  of  as  canaliculi. 
Studded  throughout  the  bone  there  are  larger  channels,  the  Haversian  canals 
carrying  the  blood-vessels.  They  are  most  numerous  in  compact  bone,  as 
the  vascular  marrow  in  the  more  cancellous  type  precludes  their  necessity. 
Li  each  canal  there  lies  an  artery  and  its  accompanying  vein,  and  the  vessels 
are  surrounded  by  a  protective  covering  of  loose  connective  tissue  which 
may  contain  lymiihatic  vessels. 

Most  of  the  lanicllao  are  arranged  concentrically  around  the  Haversian 
canals,  constituting  Haversian  systems.  Some  are  arranged  parallel  to  the 
periosteum,  the  ])eriostcal  lamellae.  Any  spaces  wliich  exist  between  the 
Haversian  and  the  periosteal  lamellae  are  occupied  by  what  are  called  the 
intermediate  lamellae. 

Piercing  the  periosteal  lamellae  in  a  vertical  direction  one  finds  vascular 
canals  similar  to  the  Haversian.  They  carry  vessels  from  the  j)eriostoum 
to  the  interior  of  the  bone,  and  they  are  called  Volkmann's  canals. 

While  the  bone  lamelUc  as  a  rule  run  parallel  they  sometimes  cross  and 
intermingle,  and  so  constitute  what  are  known  as  the  "  decussating  fibres  of 
Shar])ey." 

The  Periosteum.  -  The  perio.steum  is  the  fibrous  vascular  membrane 
which  covcr.s  tlie  cxtrrior  of  a  bone.  It  is  arranged  in  two  layers,  an  outer 
fibrous, in  which  the  blood-vessels  run,  and  an  inner  cellular  :iiid  osteogcnetic, 
endowed  with  active  bone-forming  properties.' 

'  Sir  William  M'Kwoii  clonics  that  the  periostt'iiiii  [lo.'i.scs.scs  boiicforiiiiiig  ])ro|nTtics. 
8eo  The  Qruwih  of  Hone,  Glasgow,  1912. 


14 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


*  ^  -      '  ^^  ^^^\* 


The  function  of  the  periosteum  is  a  double  one — it  helps  to  maintain  the 
nutrition  of  the  bone  by  the  blood  and  lymph  vessels  which  it  contains,  and 
by  virtue  of  its  cellular  layer  it  is  the  medium  by  which  a  bone  increases 
in  thickness.  In  the  "  resting  stage,"  i.e.  when  no  special  demands  upon 
the  periosteum  arise,  the  cellular  layer  is  thin  and  imperfect ;  when  special 
demands  for  activity  are  called  for  the  layer  becomes  thick  and  active. 

There  is  an  important  detail  which  must  be  mentioned  in  regard  to 
the  relationship  which  the  periosteum  bears  to  the  epiphyseal  cartilage. 
AVhen  the  periosteum  comes  into  contact  with  the  edge  of  the  epiphyseal 
cartilage,  it  sphts  into  two  layers — one,  the  outer,  is  continued  onwards 
over  the  epiphysis,  the  other  turns  acutely  inwards  and  is  continuous  with 
the  deeper  layers  of  the  epiphyseal  cartilage.     This  anatomical  detail  is 

explanatory  of  the  fact 
that  a  subperiosteal  ab- 
scess cannot  easil}'  infect 
the  epiphysis  or  the 
neighbouring  joint. 

The  Articular  Car- 
tilagfe.  —  The  articular 
cartilage  is  a  cap  of 
hyaline  cartilage  covering 
that  portion  of  a  bone 
which  enters  into  the 
formation  of  a  joint.  It 
extends  over  the  extre- 
mity of  the  bone,  and 
meets  peripherally  the 
periosteum  covering  the 
shaft.  The  cells  of 
articular  cartilage  are 
more  numerous  than 
those  of  ordinary  hyaline 
cartilage,  the  ground  substance  is  correspondingly  less.  The  cartilage  cells 
are  arranged  on  a  uniform  plan. 

Peripherally  the  cells  are  small  and  flattened,  arranged  with  their  long 
axes  parallel  to  the  surface.  Deeper  the  cells  proliferate  and  become  arranged 
in  columns,  springing  radially  from  the  head  of  the  bone. 

Where  the  periosteum  joins  the  articular  cartilage  the  fibres  of  the 
periosteum  actually  pass  inwards  between  the  cells,  and  separating  them 
become  uniform  with  the  gromid  substance  of  the  cartilage. 

The  Epiphyseal  Cartilag'e. — It  is  by  means  of  the  epiphyseal  cartilage 
that  a  bone  increases  in  length. 

is  an  essential  feature  at  each  extremity  of  the  long  bones, 
short  long  bones  possess  only  a  single  epiphyseal  cartilage. 

Macroscopically  it  appears  as  a  thin  plate  of  bluish  cartilage  separating 
epiphysis  from  diaphysis;  microscopically  it  is  cartilage  of  the  hyaline  variety. 


Fi(!.  2. — Pacinian  bodies  in  the  periosteum. 


Situated  near  the  articular  cartilage  it 

Most  of  the 


PI, ATI-:   III.— -A   Volkmann's  Canai.  in  Seition. 
It  cniitaiii^  :ui  artery,  n  vi'in,  two  1\  iii|ilialii's,  and  a  iniaiitity  of  lnosi-  rouia'ctivi'  tissue. 


THE  PATHOLOGY  OF  TUBERCULOSIS  OF  BONE     15 

Each  plate  of  cartilage  can  be  diflferentiated  into  two  distinct  zones. 
Lnmediately  beneath  the  bone  of  the  epiphysis  there  is  a  zone  of  clear 
cartilage,  typically  hyaline  in  appearance,  but  rather  sparsely  provided  with 
cells ;  at  a  lower  level  there  is  a  zone  which  is  scarcely  recognisable  as 
cartilage  ;  it  forms  nine-tenths  of  the  total  thickness  of  the  plate,  and  its 
structure  is  essentially  cellular. 

The  cells  of  this  second  zone  are  actively  proliferating,  and  they  are 
arranged  in  pod-like  spaces  in  which  the  cells  are  packed  together  exactly 
like  peas.  Where  the  cartilage  lies  actually  in  contact  with  the  diaphysis, 
the  cells  have  escaped  from  their  collective  confinement,  and  they  form 
irregular  masses  l3'ing  upon  the  diaphysis.  These  escaped  cells  are  large, 
oval,  or  circular,  each  with  a  distinct  cell  membrane,  a  considerable  amount 
of  cytoplasm  and  a  nucleus  containing  eosinophile  granules. 

The  superficial  layer  of  the  epiphyseal  cartilage  plays  no  part  in  the 
ossification  of  the  bone,  it  is  from  the  deeper  layer  that  this  entirely  proceeds. 
Calcareous  material  is  deposited  between  the  cells,  and  passing  inwards, 
later  invades  the  cell  membrane. 

The  Epiphysis. — In  structure  the  epiphysis  is  similar  to  the  meta- 
physis,  but  the  interstices  of  its  substance  contain  only  red  marrow. 

The  Diaphysis. — The  diaphysis  or  shaft  of  the  bone  is  filled  with  yellow 
marrow,  except  the  portion  which  immediately  abuts  upon  the  epiphyseal 
cartilage  and  which  contains  red  marrow. 

Bone  Marrow. — One  has  no  intention  of  entering  into  any  depth  of 
detail  regarding  the  structure  of  the  bone  marrow,,  but  sufficient  must  be 
said  to  make  clear  certain  points  in  pathology. 

Different  types  of  marrow  have  been  classified,  depending  upon  the 
variety  and  number  of  cells  present.  If  many  of  the  blood-forming  cells 
and  their  derivatives  occur,  the  marrow  is  spoken  of  as  red  marrow. 
Absence  of  the  cellular  element  and  the  proliferation,  apparent  or  real,  of 
the  fatty  element  results  in  the  production  of  yellow  marrow. 

There  is  a  third  variety,  of  which  more  will  be  said  later,  namely,  the 
myxomatous  or  embryonic  marrow.  It  results  from  a  proliferation  of  the 
loose,  fine  connective  tissue,  which  everywhere  supports  the  cellular  elements. 

The  actual  marrow  cells  are  classified  into  different  divisions,  according 
to  the  presence  or  absence  of  granules  in  the  protoplasm  and  tlie  character 
of  these  granules. 

A.  Tliere  are  noii-granuhir  ceils,  and  ])robab!y  two  varieties  of  such. 

(i.)  Large  non-granular  bas()))hilic  cells, 
(ii.)  Small  non-basophiiic  ceils. 

B.  There  are  granular  celi.s,  subdivided  according  to  the  type  of  granule 
wliicli  the  cells  contain. 

(i.)  Neutr<)])hiie   myelocytes,   the  forerunner  of   the    polymorpho- 
nuclear leucocytes, 
(ii.)  ]'>)sinophile  myelocytes, 
(iii.)  Basophile  myelocytes  including  mast  cells. 

C.  There  arc  precursors  of  red  blood  cells;   these  are  characterised  l>y 


16  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

their  nuclei,  and  they  are  subdivided  according  to  size  into  normoblasts, 
megaloblasts,  and  microblasts. 

D.  Finally,  there  remain  fat  cells,  connective  tissue  cells  and  different 
varieties  of  giant  cells. 


The  Histology  and  Histogenesis  of  the  Original 

Tubercle 

When  tuberculosis  attacks  a  bone  it  develops  primarily  as  an  osteo- 
myelitis, and  the  changes  which  lead  to  the  development  of  the  primary 
tubercle  originate  entirely  within  the  marrow.  The  infection  reaches  the 
marrow  by  one  of  two  possible  routes.  (1)  It  is  carried  directly  inwards  by 
the  blood  stream — the  intravascular  infection.  (2)  It  extends  into  the  marrow 
along  the  perivascular  tissues,  more  especially  in  relation  to  the  vessels 
which  connect  the  interior  of  the  end  of  a  bone  with  the  synovial  membrane 
of  the  neighbouring  joint — the  'perivascular  infection.  While  the  final 
development  of  the  tubercle  is  similar  in  both  these  varieties,  the  preliminary 
histogenesis  and  histology  varies. 

1.  The  Intravascular  Tubercle. — The  tubercle  originates  as  the 
result  of  an  intravascular  infection,  caused  probably  by  occlusion  of  the  vessel 
lumen  with  an  embolus  charged  with  tubercle  bacilh.  At  the  point  where 
the  infection  has  occurred,  upon  the  vessel  wall,  there  appears  a  circum- 
vascular  area  of  tissue  necrosis.  It  is  an  area  of  a  diffuse  ground-glass 
appearance,  and  it  owes  its  origin  to  the  toxic  effects  of  the  neighbouring 
arrested  bacilli. 

Around  this  central  necrotic  area  there  is  a  ring  of  mononuclear  cells 
and  more  peripherally  a  granular  change  in  the  fat  cells,  which  apparently 
residts  from  a  breaking  up  of  the  fat  and  the  deposit  of  crystals  of  fatty 
acids.  Such  constitutes  the  earliest  stage-in  the  development  of  the  intra- 
vascular tubercle. 

Epithelioid  cells  next  make  their  appearance  ;  they  probably  originate 
from  the  mononuclear  cells  and  the  connective  tissue  cells  of  the  part,  and 
they  can  be  recognised  by  their  irregular  shape,  the  excessive  amount  of 
faintly  granular  protoplasm  and  the  whorl-like  arrangement  of  the  nuclear 
chromatin.  These  cells  intermingle  with  the  ring  of  mononuclear  cells, 
they  pass  through  the  ring  and  invade  the  central  necrotic  area.  The  focus 
has  now  the  appearance  of  a  tuberculous  follicle,  viz.  a  cluster  of  epithelioid 
cells,  and  a  surrounding  zone  of  mononuclears. 

2.  The  Perivascular  Tubercle.  —  Disease  of  the  neighbouring 
synovial  membrane  is  the  usual  source  from  which  the  perivascular  tubercle 
of  bone  develops.  The  lymphatics  become  invaded,  and  the  development 
of  the  tubercle  is  slower  and  gradual.  Changes  occur  in  the  vessel  in 
relation  to  which  the  affected  lymphatics  run  (vascular  changes),  and  in 
the  tissues  around  the  vessel  (perivascular  changes). 

Vascular  Changes. — The  lodgment  of  the  infection  in  the  perivascular 


I'LATK    IV.— Thk  Histolojy  ok  the  Okuiinal  Tubkulli:. 


a,  All  caily  stage  in  tile  ilevelopnient  of  a  tuberciiloiis  foUiele  in  the  marrow.  A  blooil-vessel,  oeelinleil  by  a 
tilbereulons  enil)obis,  lias  beeoine  tlie  centre  of  a  celUilar  iiiBlti'atioii.  Ii,  Vaseiilar  oliaiige<  secoiulary  to  the 
developiiient  of  a  tiibeniilons  folliele.  The  endothelial  eells  lining  the  blooil-vessel  are  beconiing  dctaeheil,  ami 
they  later  become  eonveitni  into  epitheliofl  ami  giant  c^ells.  r,  A  fnrtlier  stage  in  the  ilevelopineiit  of  the  niarrow 
tulierele.  Tile  hnigment  of  the  bai-illiH  has  jji-ijilueed  a  surroiiniling  neeroti<*  area,  through  the  centre  of  which  a 
blood-vessi'l  runs.  The  infection  probably  originated  in  tliis  vessel,  d.  The  eilge  of  a.  tnbercillons  follicle  ;  a 
liniiting  baml  of  tibrou»  tissue  is  beginning  to  be  deposited. 


'-NfSfe' 


*.•»-  ■.*  •  ■    i    ■^ 


<' 

*:^/-.. 


5,'  "^  .  •  "  V  '        a      J 


'I 


^'--y:::^^ 


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MF 


-MM 


"<<JL^^ 


%&^^ 


■I 


-isnfV, 


PLATE    V. — The  HisTiiLiiiir  of  the  Obii;inal  Tubeecle. 


a,  Tlie  developing  tuliercnlous  follicle.  The  central  neerotie  area  is  lieginniiig  to  be  iiivailed  Iiy  lymphocytes. 
bf  A  tuberculous  follicle  with  giant  cell  formation  in  the  marrow.  One  of  the  giant  cells  shows  commencing 
calcification,  c,  A  fully  developed  follicle  with  a  large  central  giant  cell,  d,  A  tuberculo\is  follicle  developing  in 
the  perivascular  ti.ssues.      e.  Multiple  tuberculous  follicles  scattered  through  the  marrow. 


THE  PATHOLOGY  OF  TUBERCULOSIS  OF  BONE     17 

tissues  at  first  gives  rise  to  an  accumulation  of  round  cells  about  the 
periphery  of  the  blood-vessel.  These  cells  are  almost  without  exception 
mononuclear,  and  they  have  been  derived  from  the  cells  of  the  surrounding 
marrow. 

With  the  accumulation  of  round  cells  changes  begin  to  occur  in  the  coats 
of  the  vessel.  The  vessel  walls  become  altered,  their  tissues  become  loosened 
and  structureless,  and  the  cells  composing  them  lose  their  nuclear  staining. 
The  hning  endothehum  undergoes  a  most  distinctive  change,  the  cells 
become  swollen  and  rounded,  and  detaching  themselves  from  the  wall,  pass 


Fig.  3. — A  lU'velopiiig  ijeriviisciilar  tuberclu.     The  tubercle  is  actually 
surrouuilinj;  the  vessel. 

into  and  later  without  the  lumen  of  the  vessel.  These  changes  are  the 
result  of  a  to.\;cinia  emanating  from  tii(!  lodged  bacilli,  and  tli(\v  result  in  a 
clotting  and  ultimate  arrest  of  tlie  blood  stream. 

Perivascular  Changes. — ^Around  the  altered  vessel  there  is  an  area  of 
tissue;  necrosis  similar  to  that  wiiich  occurs  in  the  development  of  the  intra- 
vascular tubercle,  and  at  tlu;  periphery  of  the  necrotic  area  one  finds  a 
limiting  ring  of  round  cells.  Epithelioid  cells  make  their  appearance,  and 
invading  the  part,  convert  it  into  the  appearance  one  associates  with  a 
typical  tuberculous  follicle. 

Thus  by  two  very  diflerent  routes  one  has  arrived  at  a  common  point  of 

development     tlu;  tuberculous  follicle.     It  is  important  to  distinguish  the 

two  very  distinct  methods  of  formation   as   they  indicate   cpiite  dill'erent 

sources  of  infection. 

o 


18  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

3.  Further  Chang-es  in  the  Original  Follicle. — The  simple  follicle, 
constituted  as  sucli  by  a  collection  of  epitlielioid  and  mononuclear  cells, 
tends  to  undergo  a  variety  of  clianges  whicli,  while  they  may  occur  in  tubercle 
anywhere,  have  certain  peculiarities  when  they  occur  in  relation  to  bone. 

Giant  Cell  Formation. — Giant  cells  are  formed  early  in  development. 
From  personal  observation  one  is  inclined  to  sujjport  Metchnikoff's  view 
that  they  owe  their  origin  to  a  confluence  of  individual  epithelioid  cells. 
They  are  unique  in  their  size  and  in  the  number  of  nuclei  which  they  may 
possess.     One  has  coimted  117  nuclei  in  a  single  cell. 

Reticulation  of  the  Follicle. — This  condition  has  been  described  by 
SchiifEel  ^  in  relation  to  tubercle  occurring  in  glands.  The  cells  in  the  epi- 
theUoid  cluster  lose  their  definiteness  and  become  transformed  into  a  branch- 
ing and  "  fluffy  "-like  structure.  The  change  is  of  frequent  occurrence  in 
bone,  and  it  denotes  more  especially  a  degree  of  chronicity  in  the  lesion. 
The  origin  of  the  condition  is  in  all  probabihty  a  metamorphosis  of  each 
individual  epithelioid  cell  into  a  branched  myxomatous  structure,  the 
interlacement  of  the  cell  processes  giving  the  characteristic  "  fluffy " 
appearance. 

Stcrroumling  Fibrosis. — The  epithelioid  cells  at  the  periphery  of  the 
follicle  tend  to  undergo  changes — possibly  having  the  effect  of  limiting  the ' 
disease — which  are  common  to  most  forms  of  tubercle,  but  which  occur 
in  bone  to  an  unusually  well-marked  extent.  The  polyhedral  cells  at  the 
periphery  become  elongated,  and  taking  up  a  uniform  laminated  arrange- 
ment around  the  edge  of  the  follicle,  they  become  converted  into  fibro- 
blasts, and,  later,  into  an  actual  capsule  of  fibrous  tissue. 

The  process  is  always  accompanied  by  changes  in  the  surrounding 
marrow  (page  19),  and  the  combination  of  both  indicates  the  ever-present 
tendency  towards  cure  which  exists  in  osseous  tubercle. 

Caseation. — Caseation  results  in  the  interior  of  the  follicle  partly  from 
a  loss  of  blood  supply  and  partly  from  the  destructive  effects  of  the  tuber- 
culous toxins.  It  is  uncommon  in  small  tubercles,  but  it  occurs  when  the 
lesion  attains  to  any  considerable  size. 

Central  Cystic  Degeneration. — This  is  a  frequent  change  and  one  not 
thoroughly  understood.  The  central  epithelioid  cells  gradually  disappear, 
leaving  a  space  containing  fibrillar  debris.  The  degeneration  begins  in  the 
centre  and  gradually  extends  to'  the  periphery.  While  the  central  cavity 
is  enlarging,  the  peripheral  cells  become  condensed  into  a  fibrous  membrane, 
devoid  of  all  trace  of  lining  epithelium.  This  degeneration  is  the  explana- 
tion of  the  curious  porous  appearance  which  certain  tubercles  possess,  e.g. 
tuberculous  dactyhtis. 

Calcification. — Calcification  rarely  occurs  in  bone  tuberculosis  ;  one  has 
occasionally  noticed  it  as  a  deposit  in  the  centre  of  the  larger  giant  cells. 
From  such  an  original  deposit  an  entire  nodule  may  become  calcified. 

^  Schiiffel,  Lymphdrusen  tuberkulose,  Tubingen,  1871. 


'^/mm^, 


PLATE  \  I.— Seci.'-ndauv  Ciianoks  in  the  Tdbkkcui.ous  Foli.rm.k. 

II,  Ui'tiiuliilioii  of  llie  tiilicTculous  follicle — note  its  "woolly"  anil  open  aiipeiinince.  b.  Cyst  fonnation  in  tlie 
centre  of  a  tiiliercnlons  foUiele.  c,  Seeomlavy  caseation  of  the  tnlierculons  follicle.  </,  Cateilication  of  a  tnliei-- 
culou.s  follicle.     Tlicr  caluilication  is  evident  as  a  clear  space  in  tlie  centre  of  a  giant  cell. 


v'J  -Js" 


M 


m^^v.  ^     .^ 


v'''  ■■ 


^^    ■'^'■; 


'*.;   . 


^:'^'- 


■  fff 


PLATE  VII.— Marrow  Chanoes  in  ToBEUcOLors  Osteomyelitis. 

a,  Healthy  boue  marrow,  h.  Yellow  bone  marrow.  Secondary  to  the  tuberculons  disease  the  cellular 
elements  tend  to  disappear  and  the  marrow  becomes  of  the  yellow  or  fatty  type,  c,  Early  fibrous  niarrow. 
Young  connective  tissue  begins  to  appear  in  the  septa  which  lie  between  the  fat  cells,  and  with  a  low  magnification 
the  marrow  acquires  a  mosaic-like  appearance.  </,  Fibrous  marrow.  The  spaces  between  the  bone  lamellae  are 
occuiiied  by  fibrous  tissue,  e,  Fully  developed  fibrous  marrow.  ./",  Fibrous  marrow.  Note  the  distinct  pen- 
vascular  arrauKenient  of  the  fibrous  tissue. 


THE  PATHOLOGY  OF  TUBERCULOSIS  OF  BONE     19 

Associated  Changes 

The  original  tubercle  appears  in  the  marrow  as  a  minute  grey  point. 
While  it  is  enlarging  and  developing,  changes  are  occurring  in  the  tissues 
which  collectively  compose  bone,  and  the  structural  alterations  which 
result  from  these  changes  are  of  importance,  as  they  account  for  many  of 
the  characteristic  features  of  the  disease. 

The  structures  which  become  altered  are  :  the  bone  marrow,  the  bone 
lamellae,  the  periosteum,  and  the  blood-vessels. 

1 .  Marrow  Changes. — The  changes  in  the  marrow  are  twofold — an 
early  or  cellular,  and  a  later  or  fibrous.  The  first  is  an  actively  antagonistic 
one,  the  second  is  more  limiting  in  its  intention. 

Cellular  Changes. — The  greyness  of  the  original  folUcle  is  always  re- 
lieved by  a  setting  of  red,  and  such  colouring  is  the  evidence  of  the  active 
changes  in  the  marrow  around. 

Microscopically  it  is  a  neutrophile  leucoblastic  reaction,  at  first  of 
immature  cells,  but  later  fully  developed  polymorpho-nuclear  neutrophils. 

The  cells  are  possessed  of  high  phagocytic  powers  ;  they  contain  quanti- 
ties of  altered  blood  pigment,  and  their  action  must  frequently  lead  to 
destruction  of  the  attacking  bacilli. 

This,  which  one  may  term  the  acute  reactionary  stage,  lasts  for  about 
120  hours  from  the  date  of  the  original  infection.  The  character  of  the  cells 
then  begins  to  change,  the  polymorphs  diminish  in  number,  and  are  replaced 
by  two  varieties  of  cell — a  small  lymphocyte  and  a  type  of  immature  lympho- 
cyte or  large  mononuclear  cell.  The  production  of  these  cells  is  of  course  very 
suggestive  of  the  development  of  tuberculosis.  The  connective  tissue  cells 
remain  constant,  the  fat  cells  appear  to  be  diminished,  but  the  diminution 
is  more  apparent  than  real.  These  changes  in  their  sequence  are  most  intense 
in  the  neighbourhood  of  the  diseased  focus,  and  they  extend  in  a  diminish- 
ing degree  throughout  the  surrounding  tissues.  The  cellular  reaction  of  the 
marrow  continues  as  long  as  the  disease  is  increasing  in  extent,  as  long, 
in  fact,  as  active  phagocytosis  is  necessary.  When  the  growth  of  the  disease 
becomes  arrested  the  cellular  reaction  disappears,  and  the  marrow  passes 
into  the  series  of  changes  which  end  in  fibrosis. 

Fibrous  Changes. — The  conversion  of  the  marrow  into  fibrous  tissue  is 
a  gradual  process  which  extends  over  some  considerable  time.  The  change 
is  inaugurated  by  a  disappearance  of  the  specialised  cells  (lymphocytes) 
witli  a  corresponding  increase  in  evidence  of  the  fat  cells,  and  the  appearance 
among  the  latter  of  a  growth  of  young  connective  tissue.  This  devclo))3 
from  two  sources  :  (a)  From  the  connective  tissue  corjmsok's  which  lie 
scattered  among  the  fat  cells,  (b)  From  connective  tissue  fibrils  which  exist 
in  the  pcrivaseidar  tissues. 

The  formation  of  connective  tissue  between  tlie  fat  ceils  of  the  marrow 
gives  rise  to  a  curious  mosaic-like  appearance.  The  fat  cells  diminish  in  size 
and  tend  to  atrophy,  and  sometimes  the  fat  becomes  broken  up  into  an 
amorphous  collection  of  analytic  products.     When  the  connective  tissue  is 


20  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

derived  from  a  perivascular  source  the  vessel  acquires  a  thickened  appear- 
ance, but  there  is  no  endovascular  change.  The  further  history  of  the 
connective  tissue  is  one  of  increasing  density,  the  fibrillse  tend  to  lie  closer 
together  and  to  become  more  compact.  The  degree  of  density  is  greatest 
in  the  immediate  neighbourhood  of  the  diseased  focus.  Fibrosed  marrow 
is  yellowish-white  in  colour  and  of  a  remarkably  firm  consistence.  These 
marrow  changes  are  the  result  of  specific  demands.  The  primary  infection 
is  that  of  an  irritant,  and  as  such  it  calls  forth  a  simple  leucoblastic  reaction. 
With  the  development  of  the  lesion  the  specific  action  of  the  tuberculous 
tissue  becomes  evident,  and  the  result  is  the  production  of  cells  specially 
antagonistic  to  tubercle,  namely,  the  lymphocytes.  When  the  antagonistic 
attitude  is  no  longer  demanded,  the  marrow  undergoes  a  sclerosing  change 
in  order  to  limit  and  encapsulate  the  focus. 

2.  Lamellap  Chang'es. — When  tuberculosis  develops  in  a  bone  the 
surrounding  lamellae  undergo  distinctive  changes.  These  changes  are  of  two 
possible  varieties,  rarefaction  of  the  lamelloe — osteoporosis,  and  thickening  of 
the  lamellae — osteosclerosis.  In  an  individual  lesion  only  one  type  of  change 
may  occur,  but  it  is  more  usual  to  find  both  types  occurring  coincidentally. 

Osteoporosis. — Rarefaction  of  the  lamellae  is  brought  about  by  true, 
absorption  of  the  bone,  or  by  a  type  of  metamorphosis.  Osteoclasts  are  the 
medium  when  absorption  is  the  end  in  view,  they  come  to  be  alongside  the 
lamellae,  and  as  a  result  of  their  action  excavations  appear  which  are  known 
as  Howship's  lacunae.  By  continuation  of  the  process  large  areas  of  bone  are 
removed,  and  individual  lamellae  in  process  of  removal  acquire  a  typical 
worm-eaten  appearance.  This  is  the  more  rapid  mode  of  rarefaction  ;  it 
is  best  seen  in  those  instances  in  which  a  considerable  portion  of  bone  must 
be  quickly  removed  and  replaced  by  a  specialised  fibro-cellular  marrow. 

The  metaplastic  is  the  second  method  of  rarefaction,  and  of  the  two  it  is 
the  more  common.  A  lamella  is  built  up  of  a  dense  connective  tissue,  im- 
pregnated with  lime  salts.  In  the  process  of  metaplasia  the  lime  salts  dis- 
appear and  the  fibrous  elements  remain.  At  first  the  position  of  the  original 
lamella  is  evidenced  by  the  unusual  density  of  the  fibrous  tissue,  but  it 
quickly  becomes  imperceptibly  merged  in  the  surrounding  tissues. 

^Vhile  one  has  drawn  an  absolute  distinction  between  these  two  methods 
of  rarefaction,  it  must  be  remembered  that  both  may  and  do  occur  synchron- 
ously in  the  same  specimen. 

Osteosclerosis. — Osteoblasts  derived  from  the  connective  tissue  cells 
are  the  media  through  which  the  lamellae  increase  in  thickness.  They 
arrange  themselves  along  the  surface  of  the  latter,  and  deposit  successive 
layers  of  dense  new  bone.  This  new  bone  possesses  certain  pecuHarities 
which  at  once  distinguish  it  from  the  old  ;  it  contains  a  greater  number  of 
bone  corpuscles,  it  stains  a  lighter  colour,  and  the  junction  hne  between 
the  old  bone  and  the  new  is  sharp  and  distinct,  with  an  edge  which  is  often 
irregular.  The  process  of  osteosclerosis  is  indicative  of  the  more  chronic 
types  of  bone  dissase ;  its  objective  is  a  limiting  one,  but  a  more  passive 
limitation  than  that  of  fibrous  marrow  for  example. 


PLATE  Vlir.— Thk   liAitKi-ACTioN  01'  Honk. 
Tin-  l;iiii*_'Il;i  i'i  lK'iii|j,-  ;iljsorliL'«l  by  rtsteodasts. 


^: 


*  'l  .-J 


PLATE   IX. — The  Lamei.lak  Changes  secondary  to  Tubehculous  Osteomvelitis. 

a,  Fibrous  metaplasia  of  Die  lamella  :  the  bone  lamella  has  reverted  into  fibrous  tissue.  /■,  Rarelattion  ol'  the 
lamella  :  the  lamella  is  beiu!;  eaten  out  and  absorbed  by  means  of  osteoclasts,  the  resulting  spaces  are  called 
"Howship's  Lacunae."  c,  Rarefaction  of  the  lamella:  only  a  small  portion  of  the  original  lamella  remains. 
<?,  Condensation  and  thickening  of  the  lamella  by  the  deposit  of  new  bone.  The  new  bone  is  deposited  by 
osteoblasts  which  may  Ije  seen  lying  in  chains  along  the  surface  of  the  lamella. 


I'LATI';    X.  -'I'iiK  Staimw  ]n    ink   Kiiiimatihn  i>v  nkw  Sriii'i;nnisTF.AL  UoNi:. 

(I.  (Vli  I'lirly  stiW  ill  tliu  deposit.  Notu  lliv  ovi-rlyiiiK  niiisLnilai-  liluvs  tlie  two  liiycrs  of  tlir  lifiiosti'uiii,  tlic 
sliKlitly  inv^'iilur  ii|i|)t'iiniiic<!  ol  the  siirllice  ol'  tlie  orifjiiml  slmd.  iiiiil  tlif  i  Diiiimmciiig  deposit  of  new  lioiie.  I>, 
Second  stage  in  the  ilejiosit.  'I'liu  new  bone  is  Kiowinx  outwunls  in  tlie  fonii  ol  spicnles.  c,  Tliiid  stiige  ill  the 
deposit.  Till'  liiine  is  now  lieiiig  deposited  in  tlie  form  of  nrclies,  ami  tlie  inteiveiiiiig  space.'*  ore  occiipiea  by 
v.-iseuliir  eoiiiiuctive  tissue. 


PLATE   XI. — The  Final  Picture  of  new  Suepehio.steal  Bone. 

There  is  a  complete  case  enveloping  the  shaft  of  the  original  bone  ;  the  centre  of  the  original  bone  shows 

a  tuberculous  osteomyelitis. 


THE  PATHOLOGY  OF  TUBERCULOSIS  OF  BONE     21 

3.  Periosteal  Chang'es. — It  is  recognised  clinically  that  a  subperi- 
osteal thickening  is  one  of  the  earliest  features  of  tuberculous  disease  of  the 
underlying  bone.  Such  a  subperiosteal  thickening  is  the  result  of  a  deposit 
of  periosteal  bone,  and  the  activity  of  the  periosteum  depends  on  an 
increased  vascularity  secondary  to  the  underlying  disease.  The  deposited 
bone  is  one  of  two  kinds,  porous  bone  or  dense  bone,  and  in  each  variety 
the  method  of  formation  diiJers. 

Method  of  Formation  of  Porous  Bone. — In  the  deeper  layers  of  the 
periosteum,  in  addition  to  numerous  osteoblasts,  there  are  always  to  be  found 
a  number  of  osteoclasts.  The  function  of  these  is  normally  in  abeyance, 
but  by  their  activity  they  carry  out  a  preliminary  which  is  essential  to  the 
later  stages  of  new  periosteal  bone  formation.  The  osteoclasts  eat  out  a 
series  of  lacunae  along  the  shaft  of  the  bone,  until  the  usually  smooth  surface 
becomes  rough  and  irregular.  Their  activity  is  short-lived,  and  the  com- 
pletion of  the  surface  excavation  is  the  signal  for  the  cessation  of  their 
labours.  As  soon  as  the  osteoclasts  cease  their  activities,  the  osteoblasts, 
which  meantime  have  been  proliferating  in  thedeeper  parts  of  the  periosteum, 
suddenly  begin  to  functionate,  and  a  thin  layer  of  new  bone  becomes 
deposited  upon  the  uneven  surface  of  the  irregular  shaft. 

The  introductory  excavation  of  the  osteoclast  is  quite  an  intelhgible 
proceeding.  If  the  periosteal  bone  had  been  deposited  upon  a  perfectly 
smooth  and  even  shaft,  it  would  have  required  only  a  slight  degree  of  violence 
to  dislodge  its  attachment,  but  the  preliminary  roughening  of  the  surface  is 
sufficient  to  prevent  the  possibility  of  this  occurring. 

After  the  first  layer  of  bone  is  deposited  a  second  tier  is  begun.  At 
certain  points  conical  projections  of  new  bone  appear.  They  extend  out- 
wards as  small  spines,  and  in  the  interspinous  intervals  there  is  a  quantity 
of  granulation  tissue  and  one  or  more  blood-vessels.  The  scheme  of  architec- 
ture undergoes  further  changes  when  tin;  spines  become  joined  at  their 
extremities,  and  a  series  of  arches  is  formed.  Successive  series  of  arches 
are  in  this  way  deposited  until  a  varying  thickness  of  porous  bone  has  been 
laid  down.  It  is  a  scheme  of  architecture  in  which  nature  combines  a 
maximum  of  strength  with  a  minimum  of  weight. 

Method  of  Formation  of  Dense  Bone. — Occasionally  the  new  periosteal 
bone  is  compact  in  character.  The  preliminaries  are  similar  to  those  in  the 
deposit  of  porous  bone,  but  in  the  later  stages  no  arches  are  formed,  the 
bone  remaining  compact  throughout.  This  is  the  metiiod  of  deposit  which 
one  finds  occurring  in  the  neighbourhood  of  joints,  the  reason  being  that 
the  amount  of  its  (l(>posit  is  luiver  excessive  ;  the  more  profuse  porous  bone 
might  easily  interfere  with  the  mobility  of  the  joint. 

4.  Chang'es  in  the  Blood-vessels. — One  cannot  fail  to  be  struck  by 
the  frequent  occurrence  of  endarteritis  ol)literiins  in  bone  tuberculosis.  The 
disease  affects  the  smaller  vessels  and  occasionally  the  primary  divisions  of 
the  nutrient  vessel.  In  histological  detail  the  changes  closely  resemble 
those  which  occur  in  syphilis,  but  the  changes  in  the  tunica  adventiliii  illus- 
trate a  distinctive  feature.     In  syphilis  the  external  coat  is  infiltrated  and 


22  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

surrounded  by  a  number  of  small  lymphocyte  cells,  in  the  endarteritis  of 
tubercle  no  such  cells  are  to  be  found,  instead  there  is  a  development  of 
perivascular  connective  tissue.  The  condition  arises  from  the  circulation 
through  the  vessels  of  a  tuberculous  toxine.  The  change  has  far-reaching 
results,  the  narrowing  of  the  vessel  lumen  gives  rise  to  considerable  disturb- 
ance in  nutrition,  and  many  of  the  fibroid  changes  in  the  marrow  are  sequelae 
to  it.  Further,  the  disease  of  the  vessel  wall  has  an  effect  on  the  local 
development  of  tubercle.  Many  of  the  cases  of  so-called  primary  tuber- 
culous disease  occurring  in  the  metaphysis  of  the  long  bones,  the  short  long 
bones,  and  the  short  bones,  owe  their  origin  to  an  antecedent  endarteritis  of 
the  larger  blood-vessels. 

The  Gross  Pathological  Varieties  of  Osseous 
Tuberculosis 

The  previous  chapter  has  been  devoted  to  what  one  might  term  the 
general  pathological  changes,  changes  which  in  some  degree  at  least  .are 
common  to  all  forms  of  the  tuberculous  lesion.  But  each  case  of  tubercu- 
losis possesses  some  peculiarity  in  its  general  features  which  justifies  its- 
classification  into  a  special  type  of  the  disease.  Therefore  one  may  classify 
four  different  varieties  : 

1.  The  encysted  tuberculous  lesion. 

2.  The  infiltrating  tuberculous  lesion. 

3.  The  atrophic  tuberculous  lesion. 

4.  The  hypertrophic  tuberculous  lesion. 

1 .  The  Encysted  Tuberculous  Lesion.  —  When  the  disease  focus, 
after  enlarging  to  a  certain  extent,  becomes  shut  off  and  locaUsed,  it  is  termed 
an  encysted  tubercle.  The  encysted  tubercle  is  the  commonest  variety, 
it  is  also  the  most  chronic,  and  its  chronicity  is  evidenced  in  every  step 
of  its  formation. 

Macroscopic  Appeara7ices. — The  fully  developed  lesion  varies  consider- 
ably in  size,  a  common  gauge  is  from  a  pea  to  a  walnut.  For  descriptive 
purposes  it  may  be  considered  in  a  series  of  zones.  The  centre  is  occupied 
by  an  area  of  translucent  jelly-like  material,  through  which  are  scattered 
a  number  of  opaque  grey  points,  rather  resembling  putty  in  appearance. 
AVhen  the  lesion  is  of  some  age  the  individual  opaque  spots  amalgamate 
and  form  a  central  caseous  patch,  which  is  surrounded  by  a  thin  shell  of 
the  original  jelly-like  material.  Passing  to  the  periphery,  there  is  a  band  of 
pinkish-white  colour  running  round  the  translucent  zone  and  sharply  defined 
from  it.  The  circumference  of  this  zone  merges  imperceptibly  in  the 
surrounding  marrow,  which  at  the  line  of  junction  is  somewhat  more 
congested  than  usual.  "When  the  disease  is  of  considerable  age,  the  central 
portion  becomes  converted  into  a  collection  of  semi-fluid  debris,  giving 
the  part  a  cystic  appearance. 

Microscopic  Appearances. — The  disease  begins  as  a  follicle  of  the  loose 
reticular  type.     It  enlarges  imtil  it  can  be  appreciated  by  the  naked  eye  as 


I'liATK     Ml.        'I'llK     Vasi'I   I.AU    ClIANlMOS    SWIINDAHY    TCI    'I'l'llKUrUI.OIS    OSTKOM YKI.ITIS. 

«,  Tuberculous  eiiilaiti'iitis.  6,  The  nutrient  vessel  of  a  bono  allVcted  with  tulicniilous  cmlnrteritis  ;  the  boiic 
itself  was  tlie  subject  of  tuberculous  disease,  c,  A  vessel  entirely  oeeluded  as  the  result  of  tuberculous 
endarteritis. 


I'LATE    XUI. 

«,  Coronal  section  through  the  head  of  the  femur  :  tlie  disease  originated  in  the  inetaphysis 
on  the  under  surface  of  the  neck  and  has  resulted  in  extensive  se(|uestrum  formation.  b. 
Encysted  tuberculous  disease  in  the  lower  end  of  the  humerus. 


THE  PATHOLOGY  OF  TUBERCULOSIS  OF  BONE     23 

a  grey  opaque  pin  point  in  a  setting  of  red  marrow.  There  is  a  ground- 
work of  branching  connective  tissue  cells,  and  the  interspaces  are  filled  with 
epitheUoids  and  mononuclears  ;   giant  cells  are  usually  present. 

The  impression  afforded  is  one  of  a  chronic  and  slowly  developing 
tubercle.  As  the  disease  develops  in  the  marrow,  it  comes  to  surround  and 
enclose  a  number  of  bone  laraellse,  and  these  latter  undergo  rarefaction  and 
absorption  by  means  of  osteoclasts,  the  slow  development  of  the  folhcle 
usually  affording  sufficient  time  for  the  absorption  to  become  complete. 
If  the  absorption  of  the  lamellae  should  not  be  complete,  the  particles 
which  are  left,  being  isolated  by  the  diseased  tissue,  undergo  necrosis,  and 
become  converted  into  small  sequestra,  commonly  known  by  the  term  "  bone 
sand."  In  the  central  clear  deposit  areas  of  caseation  appear,  and  they  may 
coalesce  into  a  patch  of  considerable  size.  Around  the  tuberculous  tissue 
there  is  a  limiting  band  of  connective  tissue.  It  is  the  pink  limiting  band 
which  has  been  noted  in  the  macroscopic  appearances,  and  it  is  developed 
from  the  connective  tissue  elements  of  the  surrounding  marrow.  The  changes 
iu  the  surrounding  marrow  are  not  extensive  ;  close  to  the  disease  the 
connective  tissue  cells  proliferate,  and  the  marrow  acquires  a  loose  fibro- 
myxomatous  character. 

One  would  summarise  the  sequence  of  events  as  follows  :  A  deposit 
of  reticulated  tubercle  appears  in  the  centre  of  the  marrow,  and  it  increases 
in  amount,  the  bone  lamellae  being  absorbed,  until  it  forms  an  appreciable 
gelatinous-looking  patch.  Caseation  appears  in  the  centre  of  the  patch, 
and  the  lesion  is  localised  by  the  formation  around  its  periphery  of  a  pale 
pink  band  of  loose  connective  tissue. 

2.  The  Infiltrating-  Tuberculous  Lesion. — Nelaton  described  an 
infiltrating  type  of  bone  tuberculosis  in  1836,  and  it  was  probably  the  first 
variety  to  be  distinctly  classified.  It  essentially  represents  the  acute  form 
of  the  disease. 

Macroscopic  Appearances. — The  naked-eye  appearances  are  best  ap- 
preciated in  a  lesion  of  some  considerable  size.  As  in  the  encysted 
disease,  there  is  a  natural  division  into  a  series  of  zones.  The  centre  is 
occupied  by  a  pale-yellow  area,  yielding  and  crumbUng  when  touched  :  it  is 
the  rarefied  bono  framework,  the  interstices  being  filled  with  caseous  debris. 

Nelaton  described  it  accurately  when  ho  called  it  rinfiltration  puri- 
forme.  Extending  around  the  central  patch  there  is  a  zone  of  grey  semi- 
transparent  tissue  (V hifiltration  f/rlse),  which  merges  almost  imperceptibly 
into  both  the  central  and  the  peripheral  tissues.  The  appearance  is  afforded 
by  the  infiltration  between  the  lamellae  of  tuberculous  granulation  tissue 
which  has  not  yet  passed  on  to  caseation.  Around  the  grey  zone  the 
marrow  is  more  congested  than  usual.  It  constitutes  the  third  or  red 
zone  {V infiltration  liee  de  vin).  At  t]w  lino  of  junction  of  the  grey  and  the 
red  the  latter  is  sometimes  modificcl  to  form  a  paler  {)iiikish  band. 

Microscopic  Appearances.  In  its  earliest  stages  tlie  infiltrating  type 
of  disease  begins  as  a  deposit  in  the  marrow  of  a  number  of  groups  of 
epithelioid  cells.     Those  coalesce  until  an  appreciable  area  is  occupied  by 


24  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

the  diseased  tissue.  The  naked-eye  appearance  is  that  of  a  grey,  semi- 
transparent  tissue  fining  the  interiamellar  spaces.  Its  exact  structure  is 
difficult  to  elucidate.  It  is  composed  of  densely  packed  masses  of  mono- 
nuclear and  epithehoid  cells.  Intercellular  connective  tissue  is  at  a  minimum, 
and  here  and  there  there  are  branching  connective  tissue  corpuscles.  There 
is  an  early  arrest  of  the  vascular  supply,  and  to  this  change  one  must  attach 
considerable  importance  ;  it  hastens  the  process  of  caseation,  and  in  all 
probabiHty  it  greatly  depreciates  any  attempt  at  resistance  in  the  surround- 
ing tissues.  Areas  of  caseation  appear  in  the  centre  of  this  semi-transparent 
diseased  tissue,  at  first  isolated  but  later  coalescing,  and  it  is  this  caseous 
change  which  gives  the  characteristic  yellow  appearance  to  the  central  part 
of  the  lesion.  As  the  disease  develops,  numbers  of  the  bone  lamellas  become 
surrounded.  When  this  occurs  an  effort  is  made  to  remove  each  individual 
lamella  by  means  of  osteoclasts,  and  in  this  the  process  of  rarefaction  consists. 
In  an  infiltrating  disease  all  active  changes  are  arrested  long  before  rare- 
faction becomes  complete,  the  blood  flow  ceases,  perhaps  the  toxicity  of 
the  bacillus  is  great ;  at  any  rate  the  process  of  absorption  is  arrested,  the 
lamella  dies,  and  as  such  it  constitutes  a  sequestrum.  Scattered  throughout 
the  tuberculous  tissue  there  may  be  numerous  sequestra  (seque^tres 
parcellaires),  each  bearing  evidence  by  its  worm-eaten  appearance  of  the 
degree  of  rarefaction  which  it  has  undergone. 

If  the  infection  has  been  specially  rapid  and  acute,  necrosis  may  occur 
before  any  degree  of  absorption  has  become  possible,  in  which  case  a  large 
lamellar  area  dies,  and  remains  in  contact  with  the  surrounding  bone  until 
it  becomes  separated  by  granulation  tissue.  Such  constitutes  a  composite 
sequestrum.  In  the  surrounding  marrow  there  is  a  leucocytic  reaction 
around  the  periphery  of  the  disease,  and  the  type  of  cell  which  constitutes 
the  reaction  is  mainly  the  polymorph,  the  representation  of  lymphocytes 
and  mononuclears  being  sparse.  There  is,  in  fact,  a  cellular  reaction  re- 
sembHng  that  which  one  finds  in  acute  infections,  and  it  has  been  sug- 
gested that  a  mixed  infection  is  the  dominating  factor  in  the  pathology  of 
infiltrating  tubercle.  Occasionally  the  cellular  reaction  becomes  modified, 
and  there  is  an  attempt  at  fibrous  limitation  of  the  disease  ;  this  is  the 
explanation  of  the  pink  band  which  one  occasionally  finds  at  the  periphery. 
The  periosteum  becomes  early  activated,  and  forms  masses  of  new  bone. 
The  details  of  the  method  have  already  been  described.  The  essential 
factor  is  a  congestion  of  the  overlying  periosteum,  secondary  to  the  central 
disease  ;  the  deposit  may  be  localised  or  it  may  extend  widely  over  the 
shaft  of  the  bone. 

Special  Features  of  Infiltrating  Tuberculosis  of  Bone  : 

(1)  The  original  tubercle  is  a  closely  packed  collection  of  epithelioid 
cells,  and  in  appearance  a  tubercle  of  the  acute  type. 

(2)  Early  in  the  course  of  the  disease  the  blood-vessels  become  occluded, 
not  by  a  chronic  process  of  endarteritis  as  one  generally  sees  in  tuberculous 
disease,  but  rather  by  a  sudden  clotting  and  destruction  of  the  epithelium. 

(3)  Caseation  early  appears  in  the  diseased  area  and  spreads  rapidly. 


N. 


^J?.l 


I'LVri;     .\l\.        I'HK    STAOKs   in    THK    UKVKI.DI'MENT    ()!•■    A.N    KNL'YSTKD    TUUKUCILOI^S    DISKASK    OF    THK    BoNK. 

»,  All  fiirly  I'licj'stiMl  tuliiTculosis  of  tlu^  lione  :  tlir  follirli-  tiikcs  tlif  form  of  ii  rcticiiliilcil  tiilxTck'.  /', 
'I'liu  I'llge  i>f  an  eni;ysleil  tiilicnjuloiis  disease,  sliowiiii;  tlif  ilevrlopnuMit  of  tlu'  limiting  filirmis  liand.  i',  'I'lu' 
tilirous  sticicture  of  tlic  liniitiu),'  lianil  :  tliiTe  is  a  ilcposil  of  new  bcHiu  upon  tlic  oiiliT  surface  of  tlie  liand.  il,  A 
central  eiicysteil  tnliiMrulous  disease. 


PLATE     XV.— iNKILTIiATINcI    TUBKRCULOUS    DISEASE    OK   THE    BoNE. 

rt,  The  advancing  edge  of  an  infiltrating  tiilieicnloiis  disease  :  tliere  is  a  comparative  absence  of  reaction 
in  the  neighbouring  marrow.  Ii,  Commencing  iiililtrating  tuberculous  di.sease  :  note  the  absence  of  a  fibrous 
reaction  in  the  n]arro\v.  c,  Acute  infiltrating  tuberculosis  of  the  bone  ;  the  lamellae  in  the  lowei-  jjai-t  of  the 
section  enclosed  in  the  disease  have  lieen  coiiverteil  into  sequestia. 


PLATE  XVI. 

IntiltratiiifJ  tuberculous  osteomyelitis  of  the  tibia.  The  central 
portion  is  occupied  by  caseous  debris  .  around  this  there  is  a  band 
of  tuberculous  granulation  tissue  infiltrating  between  the  lamellae 
U'infiltration  griseh  at  the  periphery  there  is  the  zone  of  congested 
marrow    U'infiltration    lie   de   vint. 


I'LATK    W  11.       iM'll.THATlNU    TlBKUCILUU.S    DiStASK    ol     THh    lill>iE. 

a,  Acutu  iiililtriiting  tuberculosis  ai)rea<Iing  up  the  centre  of  the  shaft  of  the  humerus.     A,  Aciilo  iiililtruliiig 
tiihiTculosis  atl'octiiiK  aliiiOHt  the  entire  interior  of  the  se.'iplioid  lione. 


PLATE  XVIII.— The  Atkophio  Type  ok  Tuberculosis  of  Bone. 
•  a  Tlie  flipper  end  of  tbe  uli.a  affectt-a  with  atrophic  tulx-iculous  disease  :  tlie  iippei-  end  of  tlie  bone  is 
markedly  eM^anded.  h,  A  vertical  section  thro>,,d,  the  upper  end  of  tlie  ulna.  The  articular  cartilage  ,s  intact, 
her  a  niirked  rarefiction  of  the  hone  lamellae  and  the  interlamellar  spaces  are  filled  >vith  tnl.erculous  grann- 
latTon  ti'sne  c,  A  transverse  section  through  the  npper  end  of  the  ulna.  The  section  shoe's  the  rarefaction  of 
the  lamellae  and  the  occupation  of  the  spaces  by  tuberculous  tissue. 


I'liA'l'K     XIX.-TllK    AlTKAHANCE    UK    THK    MaIUIUU     IN    AtHOI'HIC    TUBElU'l'LOSl.s. 

Noll'  tlie  liiiL'fftctioii  of  tliu  liiiiii'lliie  and  the  icpliiCfiiR'Ht  of  tlie  iniirrow  1)y  tuberculous  granulation  tissue. 


PLATE   XX. — Atrophic  Tubeuculous  Disease  of  Bone. 

rt,  The  appearance  of  the  bone  in  transverse  section.      Note  the  extreme  rarefaction  of  the  bone  and  the  case  of 
new  subperiosteal  bone,     b.  Atrophic  tuberculous  disease  of  tlie  bone  in  transverse  seetion. 


THE  PATHOLOGY  OF  TUBERCULOSIS  OF  BONE     25 

It  results  partly  from  the  toxicity  of  the  bacillus  and  partly  from  the  inter- 
ference with  the  blood  supply. 

(4)  Sequestra  of  varying  forms  occur,  and  they  are  the  result  of  necrosis 
appearing  before  rarefaction  is  complete. 

(5)  The  attempt  on  the  part  of  the  marrow  and  the  surrounding  tissues 
to  localise  the  disease  is  inefficient,  and  consists  in  an  accumulation  of  cells 
rather  than  a  fibrous  reaction. 

(6)  The  disease  has  a  characteristic  spreading  and  infiltrating  character. 
3.  The  Atrophic  Tuberculous  Lesion.— The  distinctive  feature  of 

this  variety  of  tubercle  is  a  wasting  and  atrophy  of  the  bone  lamellae.  In 
some  respects  it  resembles  the  caries  sicca  first  described  by  Volkmann  ^  in 
1879,  and  later  by  Koenig^  in  1896  ;  but  on  the  other  hand  it  has  charac- 
teristics which  associate  it  with  the  caries  carnosa  of  Koenig  and  the  tuber- 
culose  charneu  of  Mauclaire.*  It  is  more  correct  to  consider  caries  carnosa 
and  caries  sicca  as  the  same  type  of  disease  in  different  stages  of  its  develop- 
ment, and  confusion  is  avoided  if  both  terms  are  combined  in  the  single 
descriptive  title  of  atrophic  tubercle.  The  reason  for  this  will  be  more 
obvious  when  the  lesion  has  been  fully  described. 

Macroscopic  Appearances. — The  situation  of  the  disease  is  typical  in 
so  far  as  it  attacks  the  metaphyseal  end  of  a  long  bone.  The  affected  bone 
is  uniformly  and  diffusely  enlarged.  It  is  much  Ughter  than  healthy  bone, 
and  its  surface  yields  to  the  application  of  a  moderate  degree  of  pressure 
with  a  curious  crinkling  sensation.  The  periosteum  undergoes  a  moderate 
degree  of  activity,  and  a  thin  sheath  of  new  periosteal  bone  is  deposited. 
On  cross  section  of  the  bone,  after  the  outer  shell  is  divided,  the 
interior  is  found  to  be  occupied  with  a  soft  granulation  tissue  in  which 
atrophied  lamolla;  are  scattered.  The  granulation  tissue  is  of  a  flesh  colour, 
and  throughout  its  substance  there  are  numerous  spaces,  producing  a  spongy 
appearance.  The  changes  may  extend  to  the  articular  cartilage,  but  the 
latter  is  never  invaded. 

Microscopic  Appearances.  Changes  in  the  Marrow. — The  earlier  changes 
appear  in  the  marrow,  and  in  their  development  they  are  slow  and  insidious. 
Gradually  the  connective  tissue  elements  increase  at  the  expense  of  the 
fatty  tissue,  and  the  marrow  becomes  transformed  into  a  variety  of  granula- 
tion tissue.  The  granulation  tissue  is  largely  composed  of  connective  tissue 
cells  of  a  myxomatous  type,  and  the  vasculaiity  of  the  part  is  considerable. 
There  are  numbers  of  mononuclear  cells  and  osteoclasts,  and  there  is  a  tend- 
ency for  the  tiss\ie  to  become  cystic.  Scattered  throughout  the  bone  there 
are  tuberculous  iollicles,  but  their  numbers  are  few,  and  in  structure  they 
are  almost  without  exception  reticulated.  As  the  disease  progresses  there 
is  an  ev(u-increasing  tendency  for  the  graiuilation  tissue  to  become  converted 
into  fibrous  tissue. 

Changes  in  the  Lamella:. — With  the  replacement  of  the  nianow  by 

'  Volluimim.  Sammlutuj  klin.  Vortrdge,  1879,  S.  1402. 

''   Koenig,  Die  7'itberculose.  der  Knochcn  und  Oelcnkcn,  1806. 

'  Mauclairp,  Maliidirs  rfci  oi,  I'aiis,  1910. 

O  » 


26  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

granulation  tissue  the  bone  lamellae  undergo  a  rapid  absorption.  It  begins 
in  the  centre  of  the  shaft,  and  it  is  the  result  of  the  activity  of  osteoclasts. 
The  absorption  extends  to  the  compact  bone  of  the  shaft,  the  lacunae 
are  increased  in  size,  and  the  whole  appearance  is  one  of  extreme  porosity. 

Changes  in  the  Periosteum. — With  the  appearance  of  radical  changes  in 
the  centre  of  the  bone,  the  periosteum  acquires  a  sudden  activity  ;  the 
result  is  the  deposit  of  a  sheath  of  new  subperiosteal  bone  of  the  vascular 
cancellous  type.  The  fm-ther  history  of  the  periosteal  bone  is  thoroughly 
distinctive  of  this  type  of  lesion.  When  a  considerable  amount  has  been 
formed,  the  foundation  from  which  it  springs  becomes  undermined  ;  that 
portion  which  Ues  in  contact  with  the  shaft  becomes  absorbed,  and  between 
the  new  bone  and  the  original  shaft  there  is  a  ring  of  granulation  tissue. 
The  periosteum  goes  on  forming  new  bone  peripherally,  but  the  deeper 
portion  continues  to  be  removed,  and  this  is  maintained  until  there  is 
a  considerable  thickness  of  granulation  tissue  separating  the  new  peri- 
osteal bone  from  the  original  shaft.  The  result  is  an  increased  but  very 
unstable  circumference. 

The  confusion  in  the  nomenclature  is  explained  by  the  changes  which 
the  lesion  undergoes  when  it  has  reached  a  certain  point  of  development ; 
the  soft  vascular  granulation  tissue  becomes  converted  into  a  dry  contracting 
granulation  tissue.  The  caries  carnosa  of  Koenig  and  the  tuberculose 
charneu  of  Mauclaire  are  descriptive  of  the  lesion  when  it  is  at  an  early 
stage  in  its  development,  and  the  granrdation  tissue  is  young  and  vascular. 
The  caries  sicca  of  Volkmann  and  Koenig  is  the  same  lesion  when  the 
granulations  have  become  fibrous  tissue  and  the  vascularity  has  diminished. 

4.  The  Hypertrophic  Tuberculous  Lesion.^ — As  there  is  a  type  of 
bone  tubercle  in  which  an  atrophy  of  the  lamellae  is  the  distinguishing 
feature,  so  there  is  a  form  in  which  a  thickening  of  the  lamellae  is  the  pre- 
dominating factor.  Its  occurrence  is  rare,  and  its  situation  is  typical  in  so 
far  as  it  attacks  the  metaphyseal  end  of  a  long  bone. 

Macroscopic  Appearances. — There  is  a  diffuse  thickening  of  the  bone, 
beginning  where  the  diaphysis  joins  the  epiphyseal  cartilage,  and  extending 
towards  the  centre  of  the  shaft.  The  periosteum  is  readily  detached,  and 
in  the  later  stages  there  is  a  deposit  of  new  subperiosteal  bone.  The  weight 
of  the  part  is  considerably  increased.  When  the  bone  is  divided  in 
transverse  section  its  structure  is  found  to  be  unusually  dense  and  firm. 
From  the  healthy  tissue  a  h3^perostosis  can  gradually  be  traced,  and  the 
hyperostosis  is  the  result  of  an  endosteal  formation.  The  thickening  is  not 
uniform  throughout  the  whole  diameter.  In  the  centre  there  is  an  area 
from  which  the  lamellae  have  been  absorbed,  their  place  being  taken  by  a 
quantity  of  grey  semi-diffluent  material.  Embedded  in  the  centre  of 
the  soft  tissue  there  is  usually  an  elongated  sclerosed  sequestrum. 

Microscopic  Appearances.      Changes  in  the  Blood-vessels. — These  are 

*  Since  the  description  of  this  lesion  was  written  the  author  has  made  observations 
which  have  led  hira  to  beUeve  that  the  hypertrophic  type  is  primarily  a  syphilitic  infection, 
secondarily  infected  with  tuberculous  disease. 


PLATiO   \\l.  —  II  vi'KH'iiun'tiK'  TruEUcui.iisis  of  the  Tibia. 
Tlu;  bone  is  IhirkeiK-il  in  its  upper  two-tliinls  .is  a  result  of  tlie  emlosteal  lieposit  tif  iii'W  hone. 


^t- 


PLATE   XXII. — HTPEKTEorHic  Tubeuculosis  ok  the  Tibia. 

a,  The  appearance  of  the  tibia.  6,  The  appearance  of  the  boue  on  transverse  section.  Note  the  central 
sequestrnm.  c,  An  early  stage  in  the  development  of  hypertrophic  tuberculosis.  There  is  an  etinsion  around  one 
of  the  branches  of  the  nutrient  vessel. 


THE  PATHOLOGY  OF  TUBERCULOSIS  OF  BONE     27 

given  the  premier  consideration  because  they  are  ujidoubtedly  the  first 
changes  to  appear,  and  probably  the  vascular  derangement  is  the  essential 
etiological  factor  in  the  pecuharities  possessed  by  this  type  of  the  disease. 
The  changes  appear  in  the  larger  divisions  of  the  nutrient  vessels  soon 
after  the  latter  break  up  into  their  primary  divisions,  and  they  take  the 
form  of  a  structureless  effusion  around  the  vessel,  and  an  endarteritis  in  the 
substance  of  its  wall.  The  perivascular  effusion  does  not  remain 
structureless,  it  becomes  organised  and  converted  into  granulation  tissue. 
The  endarteritis  in  the  wall  progresses,  and  the  vascular  and  perivascular 
sclerosis  soon  leads  to  an  almost  complete  obliteration  of  the  vessel  lumen. 
It  is  a  peri-  and  an  endarteritis. 

Changes  in  the  Lamellce. — When  the  thickening  of  the  central  vessels 
has  developed,  the  lamellae  immediately  surrounding  the  vessel  undergo  an 
absorption  and  a  fibrous  metaplasia.  These  changes  depend  upon  nutri- 
tional disturbances,  resulting  from  the  thickened  blood-vessel.  Where 
the  lamellae  have  become  absorbed  the  resulting  space  is  occupied  by  a 
fibromyxomatous  tissue.  Outside  the  central  area  of  absorption  the 
lamellae  become  thickened  and  the  hyperostosis  results  from  the  deposit 
of  bone  by  osteoblasts  lining  the  lamellar  surfaces.  It  is  essentially  an 
endosteal  thickening,  and  the  result  is  a  remarkably  firm  dense  bone. 

Formation  of  Sequestrum. — When  an  area  in  the  interior  of  the  bone 
has  been  absorbed  and  replaced  by  granulation  tissue  a  variety  of  sequestrum 
occurs  about  the  centre  of  the  bone.  It  is  the  type  of  sequestrum  which 
OlUer  ^  called  le  sequestra  dur.  Its  method  of  formation  is  as  follows : 
A  number  of  osteoblasts,  assuming  a  sudden  activity,  deposit  a  quantity  of 
closely  arranged  new  bone  in  the  centre  of  the  area  from  which  the  lamellae 
have  been  absorbed.  This  original  deposit  is  not  permanent,  when  it  has 
reached  a  certain  size  it  becomes  absorbed  and  redeposited  as  a  firmer, 
denser  bone.  This  .process  of  absorption  and  remodelhng  is  repeated  until 
the  deposit  is  densely  sclero.sed.  Up  to  this  point  of  development  the  term 
sequestrum  is  a  misnomer,  the  tissue  is  not  dead.  Later  it  becomes  a  true 
sequestrum  from  the  interference  with  its  blood  supply.  These  are  the 
appearances  which  one  finds  on  cutting  through  the  centre  of  the 
diseased  bone  :  an  outer  zone  of  hyperostosis,  an  elongated  central 
sclerosed  sequestrum,  and  an  intermediate  area  of  soft  granulation  tissue. 

Changes  in  the  Marrow. — Mention  has  been  made  of  the  formation  of 
fibromyxomatous  tissue  in  the  centre  of  the  bone.  Generally  the  marrow 
undergoes  a  fibrous  degeneration.  True  histological  evidence  of  tubercle 
occurs  in  the  shape  of  a  number  of  follicles  developing  in  the  granulation 
tissue  in  the  centre  of  the  bone. 

Changes  in  the  Periosteum. — In  the  early  stages  of  the  disease  the 
periosteum  shows  no  reaction,  and  the  thickening  is  entirely  endosteal  in 
its  origin.  In  later  stages  the  periosteum  is  activated,  and  deposits  a  thin 
layer  of  new  bone  around  the  sclerosed  shaft. 

The  changes  in  the  disease  are  essentially  those  of  a  chronic  infection. 

'  OUior,  Encijc.  ititernal.  rfc  cliirurg.,  1885. 


28  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

The  primary  endarteritis  of  the  nutrient  vessel  is  the  original  change,  and 
it  depends  on  the  circulation  within  the  vessel  of  a  tuberculous  toxine. 
The  thickening  of  the  vessel  wall  results  in  a  focal  nutritional  disturbance, 
an  absorption  of  the  surrounding  bone,  and  its  replacement  by  granulation 
tissue.  The  irritation  of  the  central  changes  leads  to  a  hyperostosis  and 
sclerosis  of  the  surrounding  lamellae.  The  actual  cytological  development 
of  tubercle  occurs  late,  and  it  is  by  no  means  the  outstanding  feature. 

Sequestrum  Formation. — In  the  progress  of  tuberculous  disease 
sequestrum  formation  almost  inevitably  results.  According  to  the  type  of 
sequestrum  three  diiierent  varieties  may  be  classified — minute  sequestra, 
(bone  sand  or  sequestres  parcellaires),  rarefied  sequestra,  and  sclerosed 
sequestra. 

Minute  Sequestra. — These  are  the  commonest,  and  they  are  met  with 
in  the  encysted  and  the  infiltrating  types  of  the  disease.  They  appear  as 
small  irregular  particles  of  bone  scattered  among  the  tuberculous  tissue. 
The  method  of  their  formation  is  as  follows :  Secondary  to  the  de- 
velopment of  tubercle  an  active  absorption  of  the  lamellae  begins,  and  is 
carried  on  by  means  of  osteoclasts.  The  absorption  has  been  almost  com- 
pleted and  the  lamellae  have  been  disorganised  into  a  collection  of  irregular  • 
particles  when  the  progress  of  the  disease  leads  to  the  arrest  of  the  circula- 
tion ;  the  broken  up  lamellae  become  converted  into  sequestra.  In 
appearance  they  are  of  varying  size  and  irregular  shape,  the  edges  are 
serrated,  the  lacunae  in  which  the  bone  corpuscles  lie  are  enlarged,  and 
the  bone  cells  have  disappeared.  The  staining  reaction  is  peculiar.  Healthy 
bone  stains  pink  with  eosin,  but  small  sequestra  take  on  the  basic  stain, 
either  as  purple  lines  or  as  a  diffuse  maroon  colour. 

Rarefied  Sequestra. — The  term  "  complete  "  would  be  more  applicable 
to  this  variety.  The  condition  is  met  with  in  acute  infiltrating  tubercle. 
The  disease  spreads  with  remarkable  activity  throughout  the  bone, 
and  large  areas  of  tissue  are  rapidly  invaded.  Attempts  are  made  by  rare- 
faction to  remove  the  invaded  lamellae,  but  long  before  absorption  is  com- 
plete, before  the  lamellae  have  reached  the  stage  of  minute  sequestra,  necrosis 
occurs,  and  the  whole  extent  of  invaded  lamellar  substance  becomes  a 
sequestrum.  At  first  the  connection  of  the  sequestrum  with  the  surrounding 
bone  is  maintained,  later  the  irritation  of  the  dead  tissue  gives  rise  to  a 
reaction  in  the  surrounding  living  bone,  and  a  line  of  demarcation  is  formed. 
The  line  of  demarcation  is  really  a  band  of  granulation  tissue,  which  being 
possessed  of  considerable  phagocytic  powers,  absorbs  the  lamellae  which 
unite  the  living  with  the  dead,  and  leaves  the  sequestrum  free. 

Sclerosed  Sequestra. — This  type  of  sequestrum  was  probably  first  de- 
scribed by  Oilier  in  1885.  He  gave  it  the  name  of  le  sequestre  dur.  It 
is  the  type  which  one  finds  in  the  hypertrophic  variety  of  bone  tubercle. 
The  origin  of  the  formation  of  the  sequestrum  is  an  irritative  one,  and  it 
is  intimately  related  to  an  endarteritis  of  one  of  the  larger  nutrient  vessels. 
The  nucleus  of  its  formation  is  a  portion  of  the  original  bone-tiss\ie,  and 
usually  a  portion  of  bone  which  either  is  already  a  sequestrum,  or  is  in  process 


n.ATi;    will.— Sta.iks  in  thk   1)kvi;i.(i|..mknt  of  IIvi'Kkticoi'iiic  Tuukhcilosis. 

«octim,'''to''  si! '17,7  "■™"'°"  •  """'."•  "  "  '"•"'if'''-""'"'  of  "'"  ™nn.,,-tlv«  tissu.  f™.nework.  6.  The  l.ono  on  t,„nsv...se 
X  t  1  will  •,  u  r"T  r  T-  '•  7t,  't''"-""'  ""'I'-^l'-""'  ^'"'i«'>  •"">"lly  occupies  tl,e  centre  of  „  l,onc 
hone  Tls  ,!.':'"  "'""■"''":"'■  ''•  '!■'■  ''O""  ""  transverse  section  :  tl,e  excessi've  fornn.tion  of  endosteal 
he  ,ele.OHe,l  Zm.st'^:,,  ■  '""  T  l\'"""' "'"'■'  '"'f""-  ^^"  endarteritis  „r  I  he  nntrient  vessels  is  illustratcl.  also 
uie  aclciosed  sequestrum  surrounded  liy  an  area  of  hone  absorpti(Ui. 


PLATE  XXIV. — A  FuLLY-DEVKLOPKD  Hypekthciphic  Tobekculosis  ok  the  Tibia. 

Tlie  shaft  is  tliickeued  by  a  deposit  of  endosteal  bone,  around  the  perijihery  there  is  a  depcsit  of 
new  periosteal  bone  and  the  interior  is  occupied  by  an  area  of  tuberculous  osteomyelitis. 


ri.A'I'i:    .\  \\  .^SEliUKSTltUM    I'oli.MATInN. 

".  A  large  composite  sequestrum  occupying  the  upper  end  of  tlie  tiV)ia.  h,  Seqiiestrcs  parceflaireii 
or  "  lioiie  siiiid"  secjuestra.  c,  The  edge  of  a  sclerosed  scqui'strum.  rf,  The  rarefiod  or  complete 
sequestrum  :  tlie  seciuestrum  occupies  the  lower  part  of  the  tiidd. 


PLATE  XXVI. — Extensive  Se<idestru,m  Formation  in  the  Interioh  ok  the  Femur. 


THE  PATHOLOGY  OF  TUBERCULOSIS  OF  BONE     29 

of  being  absorbed.  Upon  this  original  nucleus  new  bone  begins  to  be 
deposited,  and  it  can  be  recognised  from  the  original  tissue  by  its  deeper 
purple  colour  when  stained  with  hsematoxylin.  At  first  the  new  bone  is 
deposited  in  an  oj)en  porous  arrangement,  but  it  does  not  remain  permanently 
so.  When  a  certain  amount  has  been  deposited,  the  deposit  is  absorbed, 
and  a  fresh  amount  laid  down.  The  second  deposit  is  more  condensed  than 
the  first.  The  process  of  destruction  and  reformation  is  repeated  several 
times  until  it  eventually  results  in  a  focus  of  dense  solid  bone.  Up  to  this 
point  of  development  the  term  sequestrum  is  a  misnomer,  the  tissue  is 
not  dead,  it  may  have  formed  upon  a  dead  nucleus,  but  the  greater  part  of 
it  is  active  and  living.  Later  it  becomes  a  true  sequestrum,  partly  from 
an  interference  with  the  circulation  and  partly  from  the  progressive 
infiltration  of  the  surrounding  tubercle. 

Possible  Sequelae  of  Bone  Tuberculosis.— From  the  original  focus 
within  the  interior  of  the  bone  a  number  of  possibilities  may  result. 

1.  The  disease  may  remain  localised  to  the  interior  of  the  bone,  giving 
rise  to  no  external  evidence  beyond  some  periosteal  thickening.  Such  a 
sequel  is  best  exemplified  in  the  encysted  variety  of  tubercle. 

2.  The  disease  may  extend  from  the  medulla  to  the  periphery  of  the 
bone,  and  forms  a  subperiosteal  cold  abscess.  Or  extending  still  further  the 
pus  forces  its  way  through  the  periosteum  to  become  a  cold  abscess  of  the 
surrounding  soft  parts. 

3.  The  whole  extent  of  the  shaft  of  the  bone  may  become  infected  with 
tubercle— a  diffuse  tuberculous  diaphysitis. 

4.  There  may  be  an  extension  of  the  disease  from  the  original  meta- 
physeal focus,  through  the  epiphyseal  cartilage  into  the  epiphysis,  and  from 
the  epiphysis  into  the  neighbouring  joint,  setting  up  tuberculous  arthritis. 

Method  of  Healing-  in  Bone  Tuberculosis.— Fibrous  tissue  is  the 
medium  which  nature  employs  in  her  attempts  to  localise  tuberculous 
disease.  In  bone  tubercle  there  is  a  considerable  tendency  towards  spon- 
taneous cure,  and  it  is  by  the  formation  of  fibrous  tissue  that  the  conversion 
is  carried  out.  Around  a  bone  focus  every  available  tissue  is  metamorphosed 
into  fibrous  tissue.  The  marrow  loses  its  cellular  character  and  becomes 
fibrous,  the  blood-vessels  are  thickened,  and  even  the  lamellae  undergo  a 
metaplasia  which  ensures  their  conversion  into  fibrous  tissue.  Beyond 
this  fibrous  barrier  the  tuberculous  disease  does  not  penetrate,  and  as  the 
surrounding  fibrous  tissue  contracts  the  diseased  focus  becomes  less 
and  less  in  extent.  Occasionally  the  central  deposit  becomes  calcified. 
Around  the  barrier  of  fibrous  tissue  a  further  reserve  is  deposited  in  the 
shape  of  thick(niod  bone  ;  the  lamoikc  become  hyperostosed  and  sclerosed. 
The  contraction  which  occurs  in  the  process  of  healing  sometimes  pro- 
duces striking  arciiitectural  alterations  in  the  anatomy  of  the  bone.  Such 
is  well  cvidi'nced  in  the  exaggeration  of  tin-  kvphosis  which  occurs  in  the 
healing  of  I'ott's  disease. 


30  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

The  Location  of  the  Lesion  in  Osseous  Tuberculosis 

When  Lexer  in  1897  investigated  the  blood  supply  of  bones,  he  in- 
stituted the  term  metaphysis  to  mean  that  portion  of  the  bone  which  lies 
immediately  upon  the  diaphyseal  side  of  the  epiphyseal  cartilage. 

In  the  metaphysis  he  demonstrated  an  intricate  and  profuse  blood 
supply,  dependent  on  the  anastomosis  in  that  area  of  two  and  possibly 
three  sets  of  blood-vessels — the  nutrient  or  diaphyseal,  the  metaphyseal, 
and  the  epiphyseal.  Lexer  further  believed  in  the  primary  emboUc  infection 
of  tubercle,  the  infected  embolus  lodging  in  the  area  in  which  the  anasto- 
mosis is  most  perfect,  and  there  producing  a  tuberculous  metaphysitis. 
For  the  short  long  bones  and  the  short  bones  there  are  further  explanations. 
In  such,  the  nutrient  vessels  enter  the  bone  about  the  centre,  and  breaking 
up  almost  immediately  into  a  leash  of  small  vessels,  the  infected  embolus 
is  arrested  at  the  division  of  the  vessel,  and  the  result  is  a  central  tuber- 
culous osteomyelitis. 

But  the  situation  of  bone  tubercle  is  governed  by  other  factors  than 
the  simple  distribution  of  the  vessels,  factors  which  are  partly  anatomical 
and  partly  pathological,  and  considering  the  subject  from  the  view  point  of 
situation  occurrence,  bone  tuberculosis  may  be  divided  into  two  groups  : 

(1)  That  which  occurs  in  the  portion  of  the  bone  lying  in  relation  to 
a  joint. 

(2)  That  which  occurs  in  a  portion  of  the  bone  not  in  any  relation 
to  a  joint. 

Group  1. — In  the  great  majority  of  cases  the  portion  of  a  bone  which 
lies  in  relation  to  a  joint  is  composed  of  an  epiphysis,  an  epiphyseal  cartilage, 
and  the  epiphyseal  end  of  the  diaphysis,  i.e.  the  metaphysis. 

Various  observers  have  pointed  out  that  in  different  bones  different 
individual  portions  of  the  bone  are  primarily  infected.  For  example,  in 
the  lower  end  of  the  femur  the  original  infection  is  a  tuberculous  epiphysitis, 
while  in  the  upper  end  of  the  femur  it  is  a  tuberculous  metaph3^sitis.  There 
has  been  much  questioning  regarding  the  factors  which  would  appear  to 
decide  the  situation  of  occurrence. 

The  primary  infection  is  a  blood-borne  one,  and  it  is  carried  by  the 
arteries  of  the  limbs  to  the  circus  vasculosus  at  the  reflection  of  the  synovial 
membrane  of  the  joint.  From  the  circus  vasculosus  there  is  a  choice  of 
two  possible  routes  by  which  the  infection  may  spread,  it  may  extend  to 
the  synovial  membrane  and  there  produce  synovial  tubercle,  or  it  may  invade 
the  bone  and  give  rise  to  a  tuberculous  epiphysitis  or  metaphysitis. 

The  situation  in  the  bone  which  becomes  infected  is  governed  by  two 
factors.  L  The  portion  of  bone  which  lies  in  relation  to  the  synovial 
reflexion.  2.  The  presence  of  vessels  passing  from  the  synovial  reflexion 
into  the  interior  of  the  bone.  The  first  factor  is  a  purely  anatomical  one. 
In  some  instances  the  synovial  reflexion  lies  in  relation  to  the  epiphysis, 
it  never  extends  beyond  the  epiphyseal  cartilage  as  far  as  the  metaphysis, 
and  instances  of  this  are  seen  in  the  upper  end  of  the  humerus,  and  in  a 


THE  PATHOLOGY  OF  TUBERCULOSIS  OF  BONE     31 

modified  degree  at  the  lower  end  of  the  femur.  In  other  cases  the  synovial 
reflexion  passes  beyond  the  epiphyseal  cartilage  and  lies  in  relation  to  the 
metaphysis,  e.g.  the  upper  end  of  the  femur  and  the  lower  end  of  the  humerus. 
An  infection  of  the  circus  vasculosus  at  the  synovial  reflexion  extends  to 
that  portion  of  the  bone  which  the  reflexion  immediately  overlies,  be  it 
epiphysis  or  metaphysis.  The  second  factor  depends  on  the  entry  of  blood- 
vessels— the  metaphyseal  vessels — from  the  circus  vasculosus  of  the  joint 
into  the  underlying  bone.  According  to  the  position  of  the  joint  reflexion 
the  vessels  enter  the  epiphysis  or  the  metaphysis,  and  they  form  the  medium 
by  which  the  infection  extends  to  the  bone. 

One  may  summarise  the  situation  by  saying  that  when  the  synovial 
reflexion  lies  entirely  in  relation  to  the  epiphysis  of  the  bone  the  epiphysis 
is  the  site  of  the  primary  tuberculous  infection ;  when  the  reflexion  lies 
beyond  the  epiphysis,  upon  the  end  of  the  shaft,  the  metaph3^sis  is  the 
first  part  of  the  bone  to  become  diseased. 

Group  2. — In  this  group  one  includes  those  bones  or  portion  of  bones 
which  do  not  lie  in  immediate  relationship  to  a  joint — the  diaphysis  of  the 
long  bones,  the  short  long  bones,  and  the  short  bones.  The  infection  is  a 
blood-borne  one,  and  it  is  in  its  origin  an  osteomyelitis.  But  there  is  one 
factor  which  is  responsible  for  localising  the  infection.  In  certain  bones 
the  nutrient  vessel  which  supplies  the  interior  becomes  infected  with  a 
chronic  tuberculous  endarteritis,  there  is  thickening  of  the  w^all  and  gradual 
obliteration  of  the  lumen.  Secondary  to  the  obstruction,  the  interior  of 
the  bone  becomes  degenerated,  the  lamellaj  become  atrophied,  the  red 
marrow  disappears  and  is  replaced  by  a  fibromyxomatous  tissue.  A  bone 
thus  changed  becomes,  so  to  speak,  predisposed  to  disease,  and  a  tuberculous 
osteomyelitis  almost  invariably  follows.  The  resistance  of  the  marrow  is 
destroyed  and  the  lumen  of  the  vessel  is  so  narrowed  that  arrest  of  tuber- 
culous material  readily  occurs.  Certain  bones  are  more  susceptible  than 
others,  and  the  condition  bears  some  resemblance  to  arteriosclerosis  in  so 
far  as  it  usually  affects  the  vessel  at  the  point  where  bifurcation  occurs. 
The  bones  which  are  most  commonly  infected  arc  those  upon  the  blood- 
vessels of  which  the  greatest  strain  is  tlirown — the  dorsal  vertebra;  of  the 
spine,  and  the  short  bones  of  the  hand  and  foot. 

BIBLIOGRAPHY 

Cadbury,  W.  W.     "  Tuberculosis  of  Bones  and  .Joints,"  Reports,  Henry  Phipps  Institute, 

1900-7,  iv.  203-233. 
Paoli,  a.     "  Due  Casi  di  ostooperiostito  tubercolaro  guariti  coi  raggi,"  Clin.  Mod.,  Firenze, 

1907,  xiii.  1085- 1094. 
LoRTAT,  .1.  Ij.,  and  .Xniioi'RO.     "  Malformations  squelettiquos  d'origino  tuberculouse,"  Bull. 

el  Mem.  .S'oc.  Med.  des  Hop.  de  Paris,  1908,  3.  S.  xxv.  260-274. 
Miller,  .M.  H.     "  Caries  .Sicca,"  .Inn.  tiimj.,  1908,  xlviii.  151. 
Conk,  S.  M.     "  Bono  Pathology  in  relation  to  General  Pathology,"  Amer.  Journ.  Orth.  Surg., 

Phil.,  1908-0,  vi.  0()7-(>l.5." 
RiDOLi'T.     "  L,a  TuhcTculoac  ossea  ed  artioolaro  nolle  case  di  pona,"  .-Inn.  di  Ippocratt,  Milano, 

1008-9,  iii.  87-90. 
VoQiu.MANN,   U.      "  Isolierto    tuberkuloso  Knoehenherde,"   Forlachr.    a.   d.   Ocb.   Rontgcn- 

sirahlcn,  Hamburg,  1908-9,  xiii.  80-89. 


32  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

Massini,  G.     Tubercidosi  ossca  ed  articolari,  Tommasi,  Napoli,  1908,  iii.  352-354. 

CowDEN,  C.  H.     "  Tuberculosis  of  Boucs,"  South  M.  and  S.,  Chattanooga,  1008,  ix.  189-193. 

Van  Mette,  B.  F.      "  Tuberculosis  of  Bone,"   Ketitucky  M.J.,   Bowling  Green,  1908,  vi. 

272-275. 
TisiEK.     "  Ost^omalacie  tuberculeuse  limitee,"  Rev.  de  Chir.,  Paris,  1908,  xxxvii.  722. 
Mauclaire.     Maladies  des  os,  Balliere  et  fils,  Paris,  1908. 
Bradford,  E.  H.     "  Tuberculosis   of   Bones  and  Joints,"  South  M.J.,  Nashville,  1909,  ii. 

613-019. 
EwiNO,  W.  G.    "  Tuberculosis  of  Bones  and  Joints,"  Wash.  Med.  Ann.,  1909-10,  viii.  383-387. 
GiMENEZ,  L.  H.     "  Artritis  tuberculosa  abierta  de  la  rodilla  derecha,"  Med.  de  nos  Ninos, 

Barcel.,  1909,  x.  83. 
Batut.     "  Syphilis  et  tuberculose  craniennes,"  Marseille  mid.,  1910,  xlvii.  290-300. 
Lentaigne.      "  Multiple  Bone  Tuberculosis  two  years  after  Treatment,"  Tr.  Royal  Acad.  M., 

Ireland,  Dubhn,  1910,  xxviii.  206. 
Marfak,  a.  B.     Maladies  des  os,  Balliere  et  fils,  Paris,  1910. 

Brown,  E.  M.     "  Tuberculosis  of  Bones  and  Joints,"  New  York  M.J.,  1910,  xcii.  905-912. 
ToEPEL,  T.     "  Tuberculosis  of  the  Bones  and  the  Joints,"  Atlanta  Journ.  Eec.  Med.,  1910-11, 

Ivi.  239-244. 
Goldthwait,  J.  E.,  Painter,  C.  F.,  and  Osgood,  C.  B.     Diseases  oj  the  Bones  and  the  .Joints, 

Boston,  1910. 
Bkown,  E.  M.      "  Tuberculose  inflammatoire  du   squelette,  I'osteomalacie  d'crigine  tuber- 
culeuse," Bull.  Acad,  de  Med.,  Paris,  1911,  3.  S.  Ixv.  22-28. 
PoNCET,  A.,  and  Leriche,  R.     "  Tuberculose  inflammatoire  du  squelette,"  Gaz.  des  H5p., 

Paris,  1911,  Ixxxiv.  3-5. 
JouoN,  E.     "  Pieces  de  tuberculose  osseuse,"  Gaz.  Med.  de  Nantes,  1911,  xxix.  33. 
Eraser,  J.     "  Observations  on  the  Situation  of  the  Lesions  in  Osseous  Tubercle,"  Edin.  M.J., 

1912,  N.S.  ix.  436-441. 
Fraser,  J.     "  The  Pathology  of  Tuberculosis  of  Bones,"  J.  Path,  and  Bad.,  1912-13,  xvii. 

254-277. 
Jones,  R.     "  Tuberculous  Disease  of  Bones  and  Joints,"  Pracl.,  London,  1913,  xc.  182-189. 


I'LATE  XXVll. — TouEncui.ous  Dactylitis. 

There  is  .i  tiilicTcviIoiis  emlarteritis  of  the  mitiieiit  vessel,  unci  iis  n  result  of  the  endarteritis  the  zone  of  bone 
supplied  by  thi'  diseased  vessel  has  undergone  rarefaction  :  the  zones  supplied  by  the  periosteal  ami  the  articular 
vessels  are  healthy. 


PLATE  XXVIII. — The  Anatomy  of  the  Articui.ak  and  Ehphyseal  Eegions. 

a.  This  illustration  indicates  the  relationship  of  the  various  structures  at  the  reflection  ol  tlie  synovial 
membrane :  the  articular  cartilage,  the  eyiiphysis,  the  epiphyseal  cartilage,  the  metaphysis,  and  the  synovial 
reflection.  Ii,  Tlie  junction  of  metaphysis  and  epiphyseal  cartilage,  c.  The  edge  of  the  aiticulai-  surfaces  showing 
the  reduplication  of  syuo\  ial  membrane  between  the  ends  of  the  bones,  f/,  The  structure  of  synovial  membrane  : 
lining  cells  and  deeper  coimective  tissue. 


TUBERCULOUS  DIAPHYSITIS  33 


TUBERCULOUS   DIAPHYSITIS 

Spina  Ventosa. — This  need  not  be  classified  as  a  distinct  pathological 
variety  of  tuberculous  disease,  because  it  is  simply  an  infiltrating  tuber- 
culosis affecting  the  diaphysis  of  a  long  bone  or  of  a  short  long  bone. 
There  are  certain  peculiar  facts  in  its  pathological  etiology,  and  they  are 
best  illustrated  in  such  a  tuberculous  diaphysitis  as  a  spina  ventosa  of 
the  phalanges  or  metacarpals.  An  endarteritis  of  the  nutrient  vessel  just 
before  and  after  it  enters  the  bone  is  the  localising  factor.  The  endarteritis 
leads  to  a  fibromyxomatous  degeneration  of  the  marrow,  which  predisposes 
the  part  to  infection  by  tubercle  bacilli. 

BIBLIOGRAPHY 

ViONARU  and  Mounguand,  E.     "  Tuberculose   diaphyaaire   spina  ventosa  des  grands  oa 

longs,"  Rei\  d'orlhnp.,  Paris,  1908,  2-  s    ix.  481-504. 
Charitonoff,  S.       Ei)i    Beilray   zur   SchafUnberkulose  der    rjrossenrohren    Knochen,  Berlin, 

1909,  C.  Siebert. 
Bkoha,  a.     "  Spina  Ventosa  de.s  grands  os  longs,"  Rco.  gen.  de  din.  e.t  de  therap.,  Paris,  1910, 

xxiv.  353-3.55. 
Benf-t,   a.,  and  Vacorand,   H.       "Spina   Ventosa  du  peronee,"   Ann.   med.,   Paris,    1910, 

xxi.  107. 
Smoler,  F.     "  Zur  chirurgisohen  Behandlung  der  Spina  Ventosa,"   Beitr.  zur  klin.  Cliir., 

Tubingen,  1910,  Ixvii.  79-95. 
Peter-S.     "Spina  Ventosa,"  Milnch.  nyd.  Wnrhensrhr.,  1911,  Iviii.  221. 
ToirRNEAU.x,  .1.  P.     "  Sur  deux  cas  do  tubereuloso  diaplivsaire,"  .-{rchives  mid.  dc  Toulouse, 

1912,  xix.  151-1,5.5. 
Mattuevvs,  v.  8.     "Tuberculosis  of  the  Shaft  of  the  Long  Bonos,"  Am.  Surg.,  1913,  Ivii. 

133-135 
Melchior.     "  Obcr   symmetrische   Diaphysontuberkulose,"   Berl.   klin.    Woclien-whr.,    1913, 

1.  513. 
Alamartine  and  Lanoeron.     "  Tumour  de  VoxtriSmit^  superieure  du  tibia  choz  un  tubcrcu- 

Icux,"  Lyon  med.,  1913,  cxx.   1177-1179. 


34  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


THE  PATHOLOGY  OF  TUBERCULOSIS  OF  JOINTS 
Normal  Anatomy  of  Joints 

The  structures  which  enter  into  the  formation  of  joints  vary  with 
the  type  of  articulation.  In  every  instance  there  are  the  skeletal  elements 
— bones  or  cartilages — and  in  addition  there  are  uniting  media,  simple  or 
intricate,  according  to  the  variety  of  joint. 

In  the  economy  of  nature  there  are  two  varieties  of  joints  :  (a)  the 
Synarthrodial,  which  permit  of  no  movement  between  the  approximated 
surfaces  ;    (b)  the  Diarthrodial  or  movable  joints. 

In  the  synarthrodial  type  the  opposing  surfaces  are  united  by  means 
of  fibrous  tissue  (suture)  or  by  hyaline  cartilage  (synchondrosis),  and  in  the 
progress  of  ossification  the  uniting  medium  tends  to  disappear. 

A  diarthrodial  joint  may  be  one  of  two  possible  varieties,  the  movement 
between  the  surfaces  may  be  limited — the  amphiarthrodial,  or  it  may  be 
free — the  diarthrodial  joint  proper. 

An  amphiarthrosis  is  united  by  ligaments  and  by  an  interposed  plate 
of  fibrocartilage,  in  the  centre  of  which  there  is  a  rudimentary  synovial 
cavity.  The  joints  belonging  to  this  group  occur  in  the  mesial  plane  of  the 
body,  and  it  includes  the  symphisis  pubis,  the  intervertebral  joints,  and  the 
joint  between  the  manubrium  sterni  and  the  gladiolus. 

The  diarthrodial  is  the  most  elaborate  and  the  most  complete  form  of 
articulation.  It  is  characterised  by  the  freedom  of  its  movements  and  the 
presence  of  extensive  lining  by  synovial  membrane.  The  diarthrodial  is 
the  type  of  joint  which  is  most  liable  to  infection,  and  the  following 
remarks  are  in  relation  to  it. 

Structures  which  enter  into  the  Formation  of  a  Joint. — The 
opposing  surfaces  of  bone  are  held  in  apposition  by  means  of  ligaments,  and 
every  diarthrodial  joint  possesses  a  ligamentous  envelope  or  capsule,  vari- 
ously arranged  thickenings  constituting  special  ligaments.  Within  the 
attachments  of  the  capsule  there  are  the  opposing  surfaces  of  the  bones, 
each  covered  with  hyaline  cartilage.  The  capsule  itself  is  lined  with  synovial 
membrane,  which  is  continued  on  to  the  surface  of  the  intracapsular  portion 
of  each  articulating  bone.  The  synovial  membrane  ceases  at  the  edge  of  the 
articular  cartilage,  and  its  most  apt  description  is  that  of  a  tube  open  at  each 
end.  Within  the  joint  interarticular  ligaments  may  extend  between  the 
opposing  surfaces  of  the  bones,  and  interarticular  fibrocartilages  or  menisci 
may  divide  the  joint  cavity  into  distinct  compartments.  All  around  the 
joint,  in  localities  between  the  synovial  membrane  and  the  surfaces  which 
it  covers,  there  is  found  a  varying  quantity  of  fat. 


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THE  PATHOLOGY  OF  TUBERCULOSIS  OF  JOINTS  35 

Structure  of  Synovial  Membrane. — Lining  the  interior  of  the  synovial 
membrane  there  are  a  number  of  flattened  endothelial  cells  ;  their  distribu- 
tion is  irregular,  in  places  they  are  absent,  in  others  they  may  exist  several 
layers  thick.  The  distribution  is  most  plentiful  at  the  synovial  reflection. 
Beneath  the  cellular  lining  there  is  a  condensation  of  connective  tissue, 
which  really  forms  a  basement  membrane.  Occasionally  the  connective 
tissue  is  prolonged  into  the  joint  in  the  form  of  pedunculated  villi  covered 
with  endothelial  cells.  The  synovial  structure  is  completed  by  a  quantity 
of  loose  connective  tissue,  largely  interspersed  with  fat  cells,  and  carrying 
a  network  of  blood-vessels. 

Blood  Supply  of  a  Joint. — The  blood-vessels  of  the  joint  freely  an- 
astomose in  the  capsule,  and  in  the  deeper  parts  of  the  synovial  membrane. 
The  vessels  are  most  profuse  at  both  synovial  reflections,  where  they  form 
a  vascular  zone  around  the  articular  extremities  of  the  opposing  bones.  To 
this  special  portion  of  the  vascular  supply  the  term  circus  vasculosus  has 
been  applied.  From  the  circus  vasculosus  the  metaphyseal  and  epiphyseal 
vessels  pass  into  the  underlying  bone. 

The  Pathology  of  Tuberculous  Joints 

The  changes  are  best  considered  under  three  distinct  headings  ; 

A.  The  formation  of  the  primary  tubercle. 

B.  The  changes  in  the  component  parts  of  the  joint,  synovial  mem- 
brane, articular  cartilage,  underlying  bone,  blood-vessels,  ligaments,  and 
soft  parts. 

C.  The  gross  pathological  varieties  of  the  disease. 

A.  The  Formation  of  the  Primary  Tubercle. — It  is  in  the  tissues 
of  the  synovial  membrane  that  the  original  tubercle  first  makes  its  appear- 
ance, and  more  especially  in  the  deeper  parts  of  the  synovial  membrane 
where  the  blood-vessels  run.  Tlie  infection  being  blood-borne  the  lesion 
quite  often  appears  in  the  wall  of  the  vessel,  and  from  this  original  deposit 
dissemination  occurs.  In  appearance,  the  follicle  is  usually  of  the  chronic 
variety,  there  is  a  well-marked  reticulum,  and  the  epithelioid  cells  are 
separated  by  intervals  of  varying  size.  Caseation  is  a  change  which  rarely 
occurs.  Giant  cells  are  commonly  present,  and,  as  in  bone  disease,  the 
giant  cells  are  peculiar  in  so  far  as  they  often  possess  an  enormous  luiniber 
of  nuclei. 

B.  Changes  in  the  Component  Parts  of  the  Joints. 

1.  Synovial  Menihram'.  Syiichronou.s  with  antl  subsequent  to  the 
development  of  the  primary  tubercle  a  whole  series  of  changes  may  occur 
in  the  synovial  membrane.  Considering  the  changes  in  their  sequence  from 
the  surface,  one  finds  that  the  lining  endothelium  may  be  considerably 
increased  in  thickness,  tlie  thickening  giving  it  a  curious  velvety  sensa- 
tion wlien  handled.  Scattered  IliKnighout  the  thickened  endotheJinni 
there  an;  distinctive  cells,  whicli  in  nuclear  arrangement  and  amount  of 
protoplasm  resemble  the  simple  epithelioid  cell.     Also  there  are  giant  cells 


36  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

scattered  about  in  isolated  positions,  and  apparently  developing  quite  in- 
dependently of  any  secondary  lesion  ;  they  are  the  result  of  a  chronic 
irritative  change.  Important  alterations  occur  in  the  connective  tissues 
— the  changes  are  sometimes  spoken  of  as  those  of  a  gelatinous  degenera- 
tion— the  tissue  fibres  become  swollen  and  pellucid,  and  the  subjacent  fat 
is  increased  in  amount. 

2.  Changes  in  the  Articular  Cartilages. — The  absence  of  blood-vessels 
renders  cartilage  practically  immune  to  the  development  of  original  tubercle, 
but  it  does  not  prevent  it  from  becoming  involved  secondary  to  disease  of 
the  synovial  membrane. 

The  changes  in  the  cartilage  may  be  described  under  two  headings  : 
(fl)  The  involvement  of  the  cartilage  from  its  superficial,  i.e.  from  its  joint, 
surface  ;  (6)  The  involvement  of  the  cartilage  from  its  deep  or  osseous 
surface. 

(«)  Superficial  Involvement.  Perichondral  Infiltration. — Koenig  ^  be- 
lieved that  the  superficial  involvement  of  the  cartilage  had  its  origin  in  a 
deposit  upon  the  articular  surface  of  a  quantity  of  fibrin,  and  by  organisation, 
of  the  fibrin  the  underlying  cartilage  became  softened  and  vascularised. 
This  view  is  not  correct.  Schlabowski  ^  has  shown  that  the  changes  begin 
where  the  diseased  synovial  membrane  is  reflected  on  to  the  bone.  The 
diseased  membrane  becomes  adherent  to  the  cartilage,  and  when  detached 
from  it  a  pitted  and  irregular  surface  is  left. 

The  granulating  diseased  synovia  is  a  vascular  tissue,  and  as  it  grows 
and  extends  it  gives  rise  to  certain  changes  in  the  underlying  cartilage. 
The  cartilage  cells  within  their  capsules  begin  to  multiply  and  the  capsules 
to  enlarge  correspondingly  ;  only  the  superficial  cells  at  first  are  affected, 
the  deeper  ones  later.  The  proliferated  cartilage  cells  are  not  healthy, 
they  shrink  and  retract  from  the  capsule  wall,  and  ultimately  degenerate 
entirely.  The  intercellular  tissue  becomes  altered.  Normally  cartilage 
is  a  matrix  in  which  there  exists  a  quantity  of  fine  connective  tissue  fibres, 
but  in  the  healthy  state  these  fibres  are  disguised  and  practically  unrecog- 
nisable. When  the  cartilage  becomes  diseased  the  connective  tissue  fibres 
proliferate  at  the  expense  of  the  matrix,  a  change  which  is  spoken  of  as 
"  fibrillation  of  the  cartilage."  It  consists  in  a  conversion  of  the  cartilage, 
at  first  into  fibro-cartilage  and  later  into  fibrous  tissue.  At  this  stage  the 
cartilage  becomes  infiltrated  with  tuberculous  granulations,  which  force 
their  way  downwards  among  the  tissue  fibres.  The  appearance  of  a  cartilage 
so  affected  is  characteristic.  Over  its  surface  there  is  spreading  a  pannus 
of  tuberculous  granulation  tissue,  derived  from  the  surrounding  synovial 
membrane.  The  underlying  cartilage'  appears  congested,  it  has  lost  its 
characteristic  glitter,  and  there  are  intervals  of  its  surface  which  are  pitted 
and  replaced  by  patches  of  soft,  vascular,  velvety-looking  tissue. 

(6)  Deep  Involvement :  Subchondral  Infiltration. — Synovial  tubercle 
begins  and  is  most  intense  at  the  reflection  of  the  membrane.     From  the 

*   KfK'iiig,  Joe.  sup.  cit. 
^  Schlabowski,  Archiv  fur  klin.  Chir.  l.x.x.  S.  762. 


[;. 


I'LATK  X.\.\      riiAX(;Ks  rN  Tin;  c.mitii.ai.i;  m.i  umiaiiv  m  'Irin  luri.nrs  l)l^^•.A^^;  nv  thk  Joint. 

a,  Pi'iiclionilial  iilii'iiition  st'comliuy  to  lUswisi'  of  llie  synovial  iiu'iiilinuii'.  To  tlii?  riglit  of  tile  illustialioii  lies 
tlic  tiilificiilous  ^'lariiilation  tissue,  to  tlii'  li'fl  tlic  caitilapt'.  Note  tlie  irregular  iilceraleil  sui'faee  of  tlio  latter. 
'',  "  Kilirillutioii  "  of  the  curtilage.  Tiiis  appearauee  is  fouml  secoiulary  to  a  spreailiiig  of  tuberculous  tissue  over 
the  surface  of  the  cartilage,  r,  Subchomlral  ulceration  of  the  cartilage  :  a  layer  of  tulierculous  granulation  tissue 
has  spreail  inwanls  from  the  cilge  of  the  joint  lictween  the  caitilage  anil  the  umlerlying  hone. 


THE  PATHOLOGY  OF  TUBERCULOSIS  OF  JOINTS  37 

reflection  it  may  extend  along  the  deep  surface  of  the  cartilage,  between  the 
cartilage  and  the  underlying  bone,  and  by  doing  so  it  constitutes  a  sub- 
chondral infiltration. 

The  infiltrating  zone  is  a  vascular  granulation  tissue,  which  does  not 
possess  an  extreme  degree  of  disease  ;  in  fact  the  cytological  evidence  of 
tubercle  is  at  a  minimum  ;  its  thickness  is  considerable,  and  it  may  under- 
mine the  whole  extent  of  the  articular  cartilage.  In  its  deeper  parts  the 
tissue  tends  to  become  fibrous,  and  by  doing  so  it  provides  the  bone  with 
a  protective  covering  or  cap.  Should  the  overlying  cartilage  be  destroyed 
the  bone  is  not  left  entirely  exposed,  but  is  protected  by  the  fibrous  shell. 
Sooner  or  later  the  result  of  the  subchondral  infiltration  is  a  casting  off 
of  the  overlying  cartilage.  It  separates  in  flakes,  or  sometimes  as  the 
complete  articular  surface  which  comes  to  lie  free  within  the  joint  cavity. 

Watson  Cheyne  ^  has  described  a  type  of  cartilage  change  secondary 
to  tubercle,  which  differs  from  the  two  already  mentioned.  He  thus 
describes  it : 

"  The  cartilage  was  intact  except  at  the  margin  and  at  one  spot  towards 
the  centre  and  anterior  surface  of  the  internal  condyle  of  the  femur,  where 
there  was  a  small  depression  on  the  surface.  .  .  .  The  depression  on  the 
cartilage  is  due  to  destruction  of  the  cartilage  at  this  point. 

"  There  are  further  a  number  of  flask-shaped  spaces  in  the  cartilage, 
which,  under  a  high  power,  are  found  to  be  filled  with  young  fibrous  ti.ssue. 
Some  of  these  spaces  communicate  with  the  surface  of  the  cartilage,  either 
freely  or  by  narrow  channels,  while  the  majority,  and  perhaps  all,  are 
connected  with  the  superficial  cancelli  of  the  bone  by  similar  channels.  At 
various  other  points  along  the  deeper  parts  of  the  cartilage  we  see  flask-like 
projections  communicating  with  the  bone,  and  when  these  occur  the  most 
superficial  cancelli  show  osteitis. 

"  I  have  not  been  able  to  find  any  tubercle  in  the  bone.  In  this  instance 
we  have  undoubtedly  destruction  of  the  cartilage  commencing  from  the 
deeper  parts  in  a  manner  totally  different  from  the  usual  modes." 

Changes  in  Ike  Vnderli/iny  Bone.  When  the  synovial  membrane  becomes 
diseased,  changes  appear  in  the  portions  of  the  bones  which  enter  into  the 
foiination  of  the  joint.  According  to  the  ))osition  of  the  attachment  of  the 
capsular  ligament,  there  lies  within  the  joint  the  epiphysis  or  the  epiphysis 
and  a  portion  of  the  metaphysis.  Both  of  these  in  the  healthy  state  contain 
red  marrow. 

Secondary  to  the  synovial  disease  the  first  change  to  appear  is  an 
alteration  of  the  red  marrow  into  yellow  marrow,  due  to  a  disappearance 
of  the  cclhilar  elements.  Insidiously  the  yellow  marrow  undergoes  an 
extensive  structural  alteration,  the  loose  connective  tissue  which  normally 
exists  in  the  spaces  between  the  fat  cells  and  around  the  blood-vessels 
proliferates,  and  l)y  its  ])r(ilif(Mation  converts  the  fatty  nuirrow  into  a  fibro- 
myxoinatous  tissue.  The  inacro.scopic  a])pearance  of  such  a  bone  changes 
from  a  red  to  a  yellow,  and  eventually  to  a  grey  gelatinous  colour. 

'    W.  \V.  CIk  viir.  'I'lthrrculi/.iis  of  Huiic«  and  Joints,  l^dndoii,  1011. 


38  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

Here  one  word  of  warning  is  necessary.  The  gelatinous  appe'arance 
of  the  marrow  is  constantly  being  mistaken  for  a  tuberculous  infection  of 
the  bone,  and  without  microscopic  evidence  it  is  sometimes  extremely  hard 
to  distinguish  between  the  two  conditions.  The  marrow  change  lowers 
the  resistance  of  the  bone,  and  renders  it  more  liable  to  a  secondary  infection. 
To  what  are  the  changes  due  ?  Their  etiology  can  be  traced  to  two 
sources — to  a  toxic  process  resulting  from  the  development  of  tubercle  in  the 
synovia,  and  to  an  endarteritis  of  the  epiphyseal  and  metaphyseal  vessels, 
itself  the  sequel  to  a  tuberculous  toxaemia. 

Changes  in  the  Blood-vessels. — Attention  has  been  drawn  to  the  import- 
ance of  endarteritis  in  tuberculous  disease  of  bones  ;  it  is  just  as  frequently 
found  in  tuberculous  disease  of  joints.  The  blood-vessels  run  in  the  sub- 
synovial  tissues,  and  they  are  most  plentiful  around  the  synovial  reflection. 

The  vessels  undergo  an  early  primary  endarteritis  and  a  later  peri- 
arteritis ;  the  perivascular  changes  form  the  starting-point  of  more  extensive 
fibrosis  in  the  surrounding  tissues.  So  marked  may  be  the  tendency  to 
vascular  obliteration  that  even  the  largest  periarticular  vessels  may  suffer. 
Lannelongue  ^  has  recorded  that  in  hip-joint  disease  the  lumen  of  the  femoral 
artery  is  considerably  narrowed. 

The  endarteritis  extends  from  the  synovial  vessels  along  the  meta- 
physeal and  the  epiphyseal  vessels,  and  many  of  the  changes  in  the  articular 
ends  of  the  bones  are  secondary  to  the  vascular  obhteration. 

Changes  in  the  Ligaments  and  Soft  Parts. — In  the  neighbourhood  of  a 
synovial  tubercle  the  surrounding  soft  parts  undergo  degenerative  changes, 
and  the  most  important  of  the  soft  parts  are  the  ligaments  which  build  up 
the  joints.  These  ligaments  are  composed  of  dense  fibrous  tissue.  Under 
the  influence  of  disease  they  become  swollen  and  gelatinous.  This  change 
depends  upon  an  increased  deposit  of  fat  in  the  surrounding  parts,  and  an 
accumulation  in  the  interfibril  spaces  of  a  myxomatous  material.  From 
these  alterations  there  results  an  abundant  laminated  tissue,  having  the 
same  character  as  cicatricial  tissue,  and  from  the  loss  of  form  and  boundary 
it  is  often  impossible  to  say  where  individual  ligaments  begin  and  end. 
Sometimes  in  the  ligamentous  degeneration  there  is  a  deposit  of  osseous 
material  in  the  shape  of  stalactites  or  plaques,  more  rarely  in  the  shape  of  a 
ferrule  of  bone,  which  produces  a  complete  osseous  ankylosis  (Henocque). 

The  changes  spread  beyond  the  ligaments  ;  the  muscles,  tendon  sheaths, 
and  the  overlying  skin  become  pale,  swollen,  and  cedematous,  and  these 
peculiarities  have  been  the  source  of  the  term  "  white  swelling."  At  a  late 
period  there  may  be  actual  involvement  of  the  soft  parts  with  tubercle ; 
the  disease  spreads  beyond  the  synovial  tissues,  burrowing  along  the  lines 
of  the  blood-vegsels. 

In  the  neighbourhood  of  the  periarticular  changes  there  are  gelatinous 
degenerations  in  the  intermuscular  tissues  (Legg  ^),  and  the  muscles  undergo 
considerable  atrophy. 

1  Lannelongue,  Abcis  froid  et  tuberculosa  osseuse,  Paris,  1881. 

2  A.  T.  Legg,  "The  Cause  of  Atrophy  in  Joint  Disease,"  Amer.  ,/.  Orth.  Surg..  190S-9, 
Ti.  84-90. 


HLAT1-:  XXXI. 

It.  Tuberculous  disease  of  the  hip  joint.  This  sprciuit-n  illustiutcs 
the  iippcarancc  of  thi;  cartilafjc  when  it  has  undergone  a  ^ub-chroiutral 
vilceration.  b.  Tuberculous  disease  of  the  hip  joint.  The  articiihit 
cartilage  shows  the  ivpical  appearance  of  a  peri-chondral  ulceration. 


I'LATK  XXXII.     TiiiiKin  uldi  s  Iiiskask 


THK    .-IVMIVIAI.    .Ml;  Mil  HANK. 


",  Myxiiiiiatons  <leKi'niT!itirm  in  tlio  sulwyiiovial  tissues;  it  is  tliis  which  Rives  the  chiiractei'i.stie  npjicttniucc  to 
lilt!  cDiicliticiii  known  as  wliiti!  swelling,  h,  Tulierculous  enilnrteritis  of  tliu  ves.sels  in  tlio  subsynovinl  tissues. 
'■.  Hone  clmMK''*  seconihiiy  to  the  di'veloimient  of  synovial  tnheivulosis.  Note  the  rarefaction  of  tlie  hunellfte  anil 
tlie  eonversinn  of  the  marrow  into  a  lihrn-nivxoinatous  tissue. 


THE  PATHOLOGY  OF  TUBERCULOSIS  OF  JOINTS  39 

According  to  Poulet,  there  is  an  ascending  degeneration  in  the  sur- 
rounding nerves ;  the  degeneration  attacks  the  smaller  filaments,  and  it 
has  been  blamed  for  much  of  the  muscular  atrophy  which  is  so  characteristic 
of  joint  tuberculosis. 

C,  The  Gross  Pathological  Varieties  of  Joint  Tuberculosis. — There 
have  been  a  number  of  different  classifications  of  joint  tubercle  ;  their  multi- 
plicity is  sufficient  evidence  of  the  fact  that  a  satisfactory  division  has  not 
yet  been  proposed.  The  most  typical  changes  of  joint  tubercle  are  evidenced 
in  the  synovial  membrane,  and  a  suitable  classification  can  be  made  by  talung 
the  synovial  changes  as  the  basis  of  the  division. 

Upon  this  understanding  one  may  divide  joint  disease  into  four  distinct 
groups  : 

(a)  Acute  miliary  tuberculous  synovitis. 

(b)  Chronic  tuberculous  synovitis. 

(c)  Granulating  or  fungating  tuberculous  synovitis. 

(d)  Fibrous  tuberculous  synovitis. 

(a)  Acute  MUiarij  Tuberculous  Sijnovilis. — This  is  the  most  acute  and 
fortunately  the  rarest  variety  of  joint  tubercle.  It  owes  its  origin  to  a 
vascular  dissemination  of  the  organism  over  the  extent  of  the  synovial 
membrane. 

Clinically,  it  may  be  difficult  to  distinguish  from  simple  acute 
synovitis.  The  interior  of  the  joint  contains  a  quantity  of  fluid,  at  first 
serous,  later  becoming  purulent.  The  entire  synovial  membrane  is  con- 
gested, and  the  lining  endothelium  is  desquamated.  Scattered  throughout 
the  synovial  tissue  there  are  numbers  of  tiny  tubercles,  many  of  them  micro- 
scopic, some  as  large  as  a  millet  seed.  They  are  rapidly  caseating,  and  each 
stands  out  as  a  yellow  centre  in  a  setting  of  red,  a  zone  of  reactionary  con- 
gestion. 

The  articular  cartilages  are  probably  unaltered,  but  upon  their  surfaces 
there  may  be  a  deposit  of  fibrin  and  desquamated  cells.  If  this  cartilage 
deposit  is  long  standing  and  becomes  vascularised,  the  underlying  cartilage 
will  undergo  a  perichondral  ulceration.  The  surrounding  ligaments  and 
soft  parts  are  swollen  and  infiltrated  with  serum.  The  blood-vessels,  intra- 
articular and  periarticular,  are  dilated. 

(h)  Chronic  Tuberculous  Synoxniis. — The  interior  of  the  joint  contains 
an  excess  of  fluid,  usually  clear.  The  synovial  membrane  is  characteristic- 
ally thickened,  it  has  a  pellucid  gelatinous  apjK'arancc,  especially  in  its 
deeper  parts,  and  everywhere  there  are  tiny  opacities  which  denote  the 
development  of  individual  tubercles.  To  the  touch  it  is  Arm,  and  it  has  a 
sensation  not  unlike  that  of  thick  india-rubber.  It  appears  paler  and  less 
vascular  than  the  surrounding  parts,  and  when  it  is  stripped  from  the  joint 
surface  an  unusual  amount  of  fat  is  found  to  have  accunuilated  beneath  it. 
When  the  synovial  membrane  is  examined  microscopically,  the  tubercles 
are  found  to  be  of  the  chronic  variety,  open  and  reticulated  in  strticfure. 
Coincident  with  the  devclo])in(Mit  of  the  tubercles  there  are  changes  in  the 


40  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

component  parts  of  the  synovial  tissue.  The  lining  epithelium  increases  in 
thickness  to  many  times  its  original  depth.  The  connective  tissue,  which 
forms  the  groundwork  upon  which  the  lining  cells  rest,  proliferates,  and 
many  of  the  fibres  are  arranged  around  the  tuberculous  follicles.  The 
surrounding  fibrous  rings  afterwards  contract,  and  the  central  tuberculous 
follicle  bulges  upon  the  surface,  affording  what  is  perhaps  the  most  typical 
appearance  in  this  variety  of  tubercle,  namely,  the  nodular  appearance  of 
the  synovial  membrane.  The  deeper  connective  tissues  become  changed, 
the  alteration  is  idiomatically  spoken  of  as  a  gelatinous  degeneration,  the 
tissue  fibres  are  swollen,  pellucid,  and  jelly-like.  The  blood-vessels  are 
thickened  and  their  lumina  correspondingly  narrowed.  The  articular 
cartilages  become  involved  late  in  the  disease  by  a  perichondral  infiltration. 
The  subchondral  infiltration  does  not  occur  in  this  variety.  There  are 
fibrotic  and  rarefactive  degenerations  in  the  underlying  bones.  The  liga- 
ments and  soft  parts  undergo  the  fibro-myxomatous  changes  which  are 
collectively  spoken  of  as  "  white  swelling." 

(c)  Fungating  or  Granulating  Tuberculous  Synovitis. — When  the  synovial  • 
membrane  is  converted  into  tuberculous  granulation  tissue  the  disease  is 
best  described  by  the  term  fungating  or  granulating  tuberculous  synovitis. 
The  synovia  becomes  so  thick  that  it  may  fill  the  entire  joint  cavity. 
It  has  a  red  proliferative  appearance,  and  it  is  soft  and  spongy  to  touch. 
Scattered  among  the  red  tissue  there  are  opaque  or  yellow  points — 
tubercles — in  some  of  which  degenerative  changes  are  occurring. 

Microscopically,  the  disease  begins  in  the  deeper  parts  of  the  synovial 
membrane  as  a  collection  of  tuberculous  follicles.  The  tuberculous  change 
rapidly  spreads,  extending  from  the  deeper  to  the  superficial  parts  of  the 
membrane.  The  tubercles  are  clusters  of  epithelioid  cells,  there  are  immer- 
ous  giant  cells,  and  caseation  readily  occurs.  Between  the  follicles  and 
generally  throughout  the  synovial  membrane  there  is  the  formation  of  an 
amount  of  granulation  tissue,  which  gives  the  characteristic  appearance 
to  the  disease.  The  granulation  tissue  is  simple  and  embryonic  in  structure. 
There  is  a  loose  reticulum  of  young  connective-tissue  fibrils,  largely  infil- 
trated with  different  varieties  of  round  cells,  and  running  through  this 
granulation  tissue  there  are  considerable  numbers  of  thin-walled  blood- 
vessels. Throughout  its  substance  there  are  scattered  hasmorrhagic  areas, 
the  results  of  rupture  of  the  thin  vascular  walls.  The  articular  cartilages 
may  be  largely  obscured  by  the  granulation  tissue,  but  the  free  surface  is 
rarely  affected  ;  there  is,  however,  a  typical  subchondral  infiltration.  A 
zone  of  granulation  tissue  forms  between  the  cartilage  and  the  bone,  exteiid- 
ing  inwards  from  the  synovial  reflection.  The  deep  surface  of  the  cartilage 
becomes  invaded,  and  large  scales  of  cartilage  are  thrown  off  into  the 
interior  of  the  joint.  When  the  articular  cartilage  is  destroyed  the  underlying 
bone  is  found  to  be  covered  with  a  protecting  cap-like  layer  of  fibrous  tissue. 
The  ligaments  and  soft  parts  are  in  a  condition  of  white  swelling,  and  it  is 
no  uncommon  thing  for  the  tuberculous  granulation  tissue  directly  to  invade 
the  soft  parts  along  the  line  of  the  blood-vessels.     The  interior  of  the  joint 


I'LATIO  XXXlll.    -'I'liK  \Ai(iKTiKs  UK  TiTiiKUcrLons  DiSKASK  OF  Joints. 
»,  TIr-  -ninnlatiiit;  tyin'  "f  >.vnnvi:il  tulKTcwl.isis.     h.  Tin-  iiiili,-iry  type  of  synovial  tuberculosis. 


PLATE   XXX1\^  — The  Vakikiies  ok  Tubehccluus  Disease  of  Joints. 
a,  Chronic  tuberculous  synovitis.     Ij.  Fibrous  tuberculous  synovitis. 


THE  PATHOLOGY  OF  TUBERCULOSIS  OF  JOINTS  41 

contains  an  excess  of  fluid,  sometimes  semi-purulent  and  often  blood- 
stained. 

(d)  Fibrous  Tuberculous  Sy)iovit'is. — There  is  a  type  of  synovial  tubercle 
which  is  associated  with  a  progressive  formation  of  fibrous  tissue.  French 
observers  have  christened  it  synovite  lubereuse,  and  Demoulin  ^  has 
associated  its  development  with  the  caries  sicca  of  bone  tuberculosis.  Its 
essential  peculiarity  is  the  conversion  of  the  entire  synovial  tissue  into 
dense  fibrous  tissue.  The  interior  of  the  joint  is  of  a  light  flesh  colour  ;  the 
synovial  surface  is  rough  and  covered  with  tiny  nodules — an  appearance 
rather  resembhng  fresh  pigskin.  Over  the  surface  there  are  numbers  of 
grey  tuberculous  follicles.  There  is  an  excess  of  fluid  in  the  joint,  and 
foreign  bodies  or  rice  bodies  are  often  present.  These  are  smooth, 
rounded  bodies,  sometimes  flattened,  sometimes  spherical,  covered  with  a 
mucous-like  exudate,  and  occasionally  attached  by  a  pedicle  of  connective 
tissue. 

Microscopical  examination  shows  that  the  characteristic  fibrosis  begins 
around  the  original  developing  follicles,  its  function  probably  being  a  local- 
ising one.  From  the  periphery  of  the  folhcle  the  fibrosis  gradually  extends 
into  the  surrounding  tissue,  and  it  progresses  throughout  the  synovial 
membrane.  The  articular  cartilage  is  not  extensively  aft'ected ;  there  is 
some  fibrillation  round  its  periphery.  The  blood-vessels  are  character- 
istically thickened.  The  rice  bodies  already  mentioned  are  found  micro- 
scopically to  consist  of  nodules  of  fibrous  tissue.  Their  method  of  formation 
is  disputed.  Reise  ^  and  Koenig*  believe  that  they  owe  their  origin  to  a 
deposit  of  fibrin  upon  the  synovial  membrane.  Should  the  deposit  become 
displaced  it  constitutes  a  rice  body.  Goldmann*  and  Garie  maintain  that 
they  are  degenerative  products  of  diseased  synovial  membrane,  and  that 
while  they  most  usually  occur  in  tuberculosis  they  may  occur  independently 
of  it. 

The  Various  Clinical  Evidences  and  Sequelae  of  Joint  Tuberculosis. 

1.  The  disease  in  tlu^  joint  may  bo  chiefly  evidenced  by  the  acouniukitiou 
within  the  joint  cavity  of  a  quantity  of  fluid — a  tuberculous  hydrops.  It 
is  analogous  to  the  ascitic  form  of  peritoneal  tubercle,  and  it  is  characteristic 
of  a  chronic  type  of  tlu;  disease. 

2.  The  joint  may  become  distended  with  tuberculous  pus.  This  may 
be  the  sequel  to  a  true  synovial  tubercle,  but  more  frequently  it  is  the 
result  of  a  sudden  invasion  of  the  joint  by  a  bone  focus. 

3.  Tuberculous  thickening  of  the  synovial  meinbi-ane  may  he  the 
outstanding  feature  of  the  disease,  the  outline  of  the  joint  is  enlarged 
according  to  the  arrangement  of  the  synovial  membrane. 

The  hyperplasia  extends  beyond  the  synovial  membrane,  and  the 
surrounding  soft  tissues  share  in  the  (■liang<'.  To  tliis  variety  the  term 
tuiiuir  (ilhu.s  or  white  swelling  has  been  applied. 

'  Oi'tiKiuliii.  Arrliites  ghi.  de  mid.,  lX!t4. 

-  R<'iso.  Diiilirlir  Zrilschr.  fiir  Cltir.  xlix.   I. 

"  KcH'iii).',  Die  Tuhrrkiilnse  dir  iiien.irlilirlini  Ocleiiken,  Horliil,   li)0(>. 

*  GuKlnmiiii,  IJcilraye  zar  kiin,  C'liii:  Bil.  xv.  3,  S.  157. 


42  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

4.  The  extension  of  the  disease  from  the  joint  into  the  surrounding 
soft  parts  leads  to  the  development  of  periarticular  cold  abscesses,  and 
these  by  bursting  through  the  skin  are  the  origin  of  sinuses. 

5.  The  infection  of  the  articular  cartilages  and  their  destruction 
permits  of  an  exposure  of  the  opposing  osseous  surfaces.  The  disease 
invades  the  cancellous  tissue  of  the  bone,  and  the  joint  becomes  disorganised. 

Method  of  Healing-  in  Joint  Tuberculosis. — The  process  of  heaUng 
in  a  tuberculous  joint  will  depend  upon  the  extent  of  the  original  dis- 
ease. If  the  disease  has  been  purely  synovial,  the  process  of  cure  will 
consist  in  a  development  of  fibrous  tissue  in  the  synovial  membrane. 
There  will  probably  be  some  degree  of  stiffness  in  the  joint.  ^Vhen  the 
disease  has  been  more  extensive  and  the  articular  cartilages  have  been 
destroyed,  the  formation  of  fibrous  tissue  is  necessarily  great.  The 
opposing  joint  surfaces  are  bound  together  by  it,  the  articular  cartilages 
and  the  synovial  tissues  become  converted  into  it,  and  the  interlamellar 
spaces  of  the  adjacent  bones  become  occupied  with  it.  Even  the  periarticu- 
lar vessels  share  in  the  fibrosis.  When  a  cure  necessitates  such  extensive 
changes  as  these,  there  naturally  results  a  fibrous  ankylosis.  Sometimes, 
just  as  in  bone  tubercle,  the  process  of  cure  extends  further,  and  the  osseous 
tissue  plays  its  part.  The  remains  of  the  joint  surfaces  become  united  by 
new  bone,  and  there  is  a  fresh  bone  formation  around  the  periphery  of  the 
joint. 

BIBLIOGRAPHY 

Arce,  J.  "  Tuberculosis  articular,"  Rev.  Soc.  Med.  Argent.,  Buenos  Aires,  1907,  xv.  377-465. 
MoRO,  G.  "  Tuberculosi  articolari,"  Boll.  d.  r.  Accad.  Med.  di  Genova,  1907,  xxiii.  251-267. 
G.iNGOLPHE.     Arthrites  tuberculeuses,  Balliere  et  fils,  Paris,  1908. 

Lego,  A.  T.  "  The  Cause  of  Atrophy  in  Joint  Disease,"  Amer.  J.  Oilh.  Surg.,  1908-9,  vi.  84-90. 
Treboulet,  H.;  Rebadean  ;  Dumas  and  Boye.   "A  Propos  d'une  observation  de  poh-arthrites 

tuberculeuses,"  Bull.  Soc.  de  Pediat.  de  Paris,  1908,  x.  285-295. 
Reinh-ARDT,  A.     "  Die  jjriniar  sklerosierende  Tuberkulose  der  Schleimbeutel,"  Deutsche  Zeit. 

fiir  CJdr.,  Leipzig,  1909,  xcviu.  63-74. 
Ely,  L.  W.     "  Joint  Tuberculosis  with  special  reference  to  its  Pathology,"  Med.  Bee,  New 

York,  1909,  Ixxvi.  551-554. 
Keith,  J.  R.     "  Acute  Tuberculous  Arthritis,"  Brit.  M..J.,  London,  1909,  ii.  205. 
TiK,  V.  A.     "'  Diseases  of  the  Joints  Etiologically  and  Pathologically  considered,  and  their 

Rational  Classification,"  Kherurg.  Arkh.  Velyaminom,  St.  Petersburg,  1910,  xxvi.  926-960. 
Daniel,  P.  L.     Arthritis  :  a  Study  of  the  Inflammatory  Diseases  of  Joints,  J.  Bale,  Sons,  & 

Danielsson,  London. 
FiNBERG,  A.  H.,  and  Woolley",  P.  G.     "  Osteochondritis  dessicans,  concerning  its   Nature 

and  Relation  to  the  Formation  of  Joint  Mice,"  Ainer.  J.  Orth.  Surg.,  Philadelphia,  1910— 

11,  viii.  477-494. 
Ely',  L.  W.     "  The  Pathology  of  Tuberculous  Joints,"  J.  Am.  M.  Assoc,  Chicago,  1910,  Iv. 

1283. 
NicHOL,  A.  G.     "Tubercular  Arthritis,"  South  M..J.,  Nashville,  1910,  iii.  317-322. 
Ely,  L.  W.      "  Further  Observation  on  the  Pathology  of  Joint  Tuberculosis  and  Practical 

Deduction  therefrom,"  Med.  Per.,  New  York,  1910,  Ixxviii.  147-149. 
Ely',  L.  W.     "  Observations  of  the  Pathology,  Diagnosis,  and  Treatment  of  Joint  Tubercu- 
losis," New  York  State  M..J.,  New  York,  1910,  "x.  273-278. 
NOTT,  J.  J.     "  Tuberculous  .Joint  Diseases,"  ./.  Am.  Med.  Assoc,  Chicago,  1911,  liv.  178. 
RiDLON,  J.     "  Joint  Disease  from  the  Orthopaedic  Standpoint,"  Illinois  M.J.,  Springfield, 

1911,  xix.  4-8. 
Broca,  a.     "  Osteoarthrites  tuberculeuses  procedees  de  type  bacilloso-tuberculose  osseuse 

a  foyers  multiples,"  Rev.  de  la  tuberculose,  Paris,  1911,  2  S.,  viii.  1-19. 


THE  PATHOLOGY  OF  TUBERCULOSIS  OF  JOINTS  43 

Albert,  Maitkin.     De   la  pijarthro.se   tubercideuse   d'origine  synoviale  saiis  lesion  osseuse, 

St.  :fitienne,  1911. 
ANzrLOTTi,  G.      "  Recerche  sperimentale   suUa   pathogenesi  dclle  artropatie  tubercolari," 

Path.  riv.  quindecim.  Geneva,  1911-12,  iv.  709-716. 
Lancial,  d'Aekas.     "  Peri-arthrite  fongeuse  chez  un  enfant,  etc.,"  J.  des  3C.  med.  de  Lille, 

1912,  ii.  481. 
Peltesohn,  S.     "  tJber  tuberkulo.se   Gelenkdeformitaten   der   unteren  Extremitaten  und 

ihre  paraartikulare  Korrektur,"  ChareVs  Ann.,  Berk.,  1912,  xxxvi.  526-544. 


44  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


THE  CLINICAL  FEATURES  OF  BONE  TUBERCULOSIS 

It  is  necessary  ttat  one  should  insist  on  the  paucity  of  symptoms  in  a 
pure  type  of  bone  tuberculosis  ;  there  is  much  confusion  between  the  symp- 
tomatology of  bone  disease  and  joint  disease.  That  the  symptoms  should 
be  few  in  the  case  of  the  bone  is  what  one  would  expect  from  the  patho- 
logical features  of  the  disease.  From  its  deep  situation  its  manifestations 
are  hidden,  and  by  reason  of  its  slow  progress  the  symptoms  have  little  of 
the  nature  of  the  acute.  But  there  are  certain  featm-cs  which  occur,  and 
they  are  best  considered  in  the  order  in  which  they  appear  in  the  jjrogress 
of  a  case. 

Local  Features 

Thickening". — Local  thickening  of  the  affected  bone  is  usually  the 
first  feature  to  appear.  Its  recognition  will  largely  depend  on  the  situa- 
tion of  the  diseased  bone,  whether  it  is  superficial  or  deep.  The  increase 
in  the  circumference  of  the  bone  is  the  result  of  a  periosteal  reaction 
and  the  deposit  of  a  quantity  of  new  subperiosteal  bone.  Its  origin  is 
insidious,  but  its  progress  is  steady,  and  it  may  advance  until  the  shaft 
of  the  bone  may  have  acquired  twice  its  original  circumference.  At  first 
the  thickening  is  yielding  and  indentable,  because  it  is  virtually  a  granula- 
tion tissue,  but  as  ossification  proceeds  it  becomes  as  hard  as  healthy  bone. 
The  original  position  of  the  deposit  is  a  fairly  exact  indication  of  the  situa- 
tion of  the  original  disease,  but  in  advanced  cases  it  may  surround  the 
entire  circumference  of  the  bone.  It  is  slightly  tender  when  palpated, 
and  in  the  early  stages  of  the  disease  there  is  no  increased  local  temperature 
or  redness.  Local  thickening,  such  as  has  been  described,  is  the  most 
characteristic  feature  of  bone  tuberculosis. 

Pain. — In  bone  disease  pain  is  the  result  of  pressure  upon  the  nerve 
endings.  Acute  conditions  in  which  the  increase  of  tension  is  rapid  and 
extreme  have  intense  pain  as  the  predominating  symptom.  In  tuberculous 
disease,  however,  the  pain  is  slight  and  frequently  entirely  absent.  While 
the  disease  is  confined  to  the  interior  of  the  bone  the  slow  progress  of  the 
infiltration  precludes  any  degree  of  tension,  and  it  has  been  suggested  that 
tuberculous  disease  exerts  a  degenerative,  or  at  least  an  ansesthetic  in- 
fluence upon  nerve  tissue.  But  in  certain  cases  pain  is  certainly  present, 
and  the  explanations  of  its  occurrence  are  as  follows  :  (1)  The  deeper  layers 
of  the  periosteum  are  well  supplied  with  nerves,  and  sometimes  the  nerve 
endings  are  of  a  highly  specialised  type.  While  the  disease  is  still  confined 
to  the  interior  of  the  bone  a  simple  serous  efi'usion  occurs  beneath  the  peri- 


THE  CLINICAL  FEATURES  OF  BONE  TUBERCULOSIS        45 

osteum  ;  the  effusion  exerts  tension  upon  the  nerve  endings,  and  local  pain 
is  the  result.  It  is  therefore  an  early  feature  in  the  sequence  of  symptoma- 
tology. And  it  is  only  temporary,  for  with  the  formation  of  new  periosteal 
bone  the  subperiosteal  tension  is  relieved.  (2)  In  the  more  rapid  infiltrating 
types  of  tuberculous  osteomyelitis  it  is  quite  possible  that  a  considerable 
increase  of  intraosseous  tension  may  occur,  and,  as  in  acute  osteomyelitis, 
pain  may  be  induced.  (3)  The  pain  met  with  may  be  not  local,  but  referred. 
There  is  an  irritation  of  nerve  trunks,  and  the  irritating  factors  vary, 
alterations  in  the  architecture  of  the  bone,  the  formation  of  masses  of 
tuberculous  granulation  tissue,  the  pressure  of  a  cold  abscess.  The  pain  is 
referred  to  the  distribution  of  the  affected  nerve  trunk,  and  the  best  illus- 
tration of  it  is  found  in  Pott's  disease,  in  which  pain  is  often  referred  to 
the  middle  line  in  front. 

Muscular  Wasting". — It  is  difficult  to  estimate  the  extent  to  which 
muscular  wasting  is  actually  secondary  to  osseous  tubercle.  In  joint  disease 
it  is  uniformly  quoted  as  a  most  outstanding  feature,  and  it  has  been  stated 
that  it  owes  its  occurrence  to  reflex  irritation  from  the  diseased  joint.  If 
such  be  its  true  explanation  in  joint  tubercle,  it  very  likely  \\'ill  explain  its 
occurrence  in  bone  disease.  But  the  difficulty  lies  in  deciding  the  question 
of  to  what  extent  atrophy  is  the  result  of  want  of  use.  The  chances  are  that 
with  the  first  appearance  of  symptoms  and  the  diagnosis  of  tubercle,  rest 
treatment  is  at  once  begun,  and  this  must  lead  to  a  certain  degree  of  disuse 
atrophy. 

Abscess  Formation.  —  As  the  disease  progresses  caseation  and 
softening  occur  in  the  interior  of  the  bone  ;  when  the  periphery  of  the  bone 
is  invaded  a  subperiosteal  cold  abscess  develops.  Presently  the  periosteum 
gives  way,  and  the  abscess  formation  extends  into  the  surrounding  soft 
parts.  Its  further  course  will  vary  according  to  questions  of  gravity, 
position,  and  tissue  arrangement. 

The  French  appreciation  of  the  pathology  of  a  tuberculous  abscess  is 
a  good  one.  'I'lioy  look  upon  the  condition  as  one  would  a  type  of  tumour 
formation,  with  central  degeneration.  Always  at  the  periphery  there  is 
the  infiltrating  tuberculous  granulation  tissue  ;  in  the  centre  there  is  usually 
caseation  and  abscess  formation.  Considered  in  this  light  it  is  not  diflicult 
to  understand  how  sometimes  the  abscess  become?  pedunculated  and  sessile, 
and  occasionally  becomes  entirely  cut  oft"  from  the  focus  which  gave  it 
origin.  'J'lie  further  stage  of  untreated  abscess  formation  is  the  opening 
on  a  free  surface  and  the  establishment  of  a  sinus. 

General  Features.  —  Three  factors  are  at  work  in  jnoducing  the 
general  fi'aturcs  of  osseous  tubercle — ^they  are  the  dissemination  of  the 
disease,  the  absorption  of  tuberculous  toxins,  and  the  occurrence  of  sinuses 
with  the  inevitable  mi.xed  infection.  The  dissemination  of  the  disease  is  not 
common.  (Hands  are  the  earliest  tissiu-s  to  become  affected,  and  a  spread 
to  llii'  mcniiigis  is  (il'tm  (lie  terminal  feature.  The  absorption  of  tuber- 
culous toxins  is  of  cdinse  continually  jiroceeding,  in  small  measure  or  in 
great.     It  produces  such   features  as  loss  of  weight,   increasing  debility, 


46  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

disordered  digestion,  and  occasional  rises  of  temperatnre.  But  far  more 
important  than  any  of  these  is  the  part  played  by  sinus  formation  and 
mixed  infection.  The  infection  of  a  cold  abscess  with  organisms  other  than 
the  tubercle  bacillus  is  often  tantamount  to  signing  the  patient's  death 
warrant.  Wlien  it  has  occurred,  a  cure  is  most  diificult  to  obtain,  and 
quickly  in  the  train  of  the  infection  there  come  the  complications  of  hectic 
fever,  emaciation,  sweating,  diarrhoea,  and  the  features  of  waxy  disease. 


THE  CLINICAL  FEATURES  OF  JOINT  TUBERCULOSIS 

In  comparison  vnth.  bone  disease,  tuberculosis  of  joints  is  accompanied 
by  a  much  wider  range  of  cUnical  features.  There  are  several  reasons  why 
this  should  be  the  case.  The  majority  of  joints  from  their  position  are 
comparatively  superficial,  and  those  which  are  movable  and  diarthrodial 
joints  are  practically  the  only  ones  affected  by  the  disease.  The  symptoms 
are  exaggerated  by  the  possibility  of  apposition  and  friction.  Following 
the  plan  hitherto  followed,  the  features  are  best  considered  in  the  order 
in  which  they  clinically  occur. 

Local  Features 

stiffness  in  Joint. — Free  and  untrammelled  action  of  a  joint  is 
very  largely  guaranteed  by  the  presence  of  synovial  fluid,  and  any  diminu- 
tion in  amount  of  this  latter  is  demonstrated  by  varying  degrees  of 
stiffness.  When  the  synovial  membrane  becomes  infected  with  tuber- 
culous disease  one  of  the  earliest  sequelse  is  a  diminution  in  the  amount  of 
true  syno^dal  fluid.  The  amount  is  least  in  the  morning,  but  as  the  day 
passes  and  the  joint  surfaces  are  stimulated  by  movements,  the  amount 
increases,  though  it  never  reaches  a  normal  standard.  One  is  therefore 
not  surprised  to  find  that  the  joint  stift'ness  so  characteristic  of  early  joint 
tubercle  has  a  distinct  diurnal  occurrence.  It  is  most  marked  after  the  joint 
has  been  rested  for  some  time,,  e.g.  in  the  morning,  and  it  disappears  after 
movements  have  been  indulged  in.  It  is  important  to  recognise  the  true 
etiology  of  this  symptom,  as  it  is  often  confused  with  the  feature  of  muscular 
rigidity. 

Alteration  in  Use  of  the  Joint.^Each  joint  possesses  a  prescribed 
degree  of  movement,  and  any  alteration  in  the  degree  is  quickly  evidenced. 
The  evidence  may  take  various  forms.  In  the  lower  extremity  it  usually 
appears  as  a  limp,  in  the  upper  extremity  it  may  be  as  an  error  in  the 
execution  of  some  of  the  finer  and  more  compHcated  movements.  What  is 
the  explanation  of  this  sign  ?  It  depends  on  an  early  degree  of  muscular 
irritability.  It  would  appear  as  though  the  muscles  were  unwilling  to  trust 
the  joint  to  its  full  range  of  movement.  In  the  lower  extremity  the  recog- 
nition of  a  limp  may  be  comparatively  easy,  but  in  the  upper  extremity 


THE  CLINICAL  FEATUEES  OF  JOINT  TUBERCULOSIS       47 

the  development  of  the  feature  may  be  so  insidious  that  very  considerable 
care  may  have  to  be  taken  before  the  condition  is  recognised. 

Alteration  in  Position  of  the  Joint. — In  certain  positions  the 
opposing  joint  surfaces  are  more  widely  separated  than  in  others,  and  it 
may  be  taken  as  a  rule,  to  which  there  are  few  exceptions,  that  flexion  is  the 
position  which  most  completely  secures  this.  Therefore  one  finds  that 
while  the  disease  in  the  joint  is  as  yet  early,  the  limb  tends  to  take  up 
an  altered  position,  and,  as  has  been  said,  usually  one  of  flexion. 

When  the  disease  is  fully  estabUshed  there  are  more  extensive  alterations 
in  position,  and  they  depend  upon  one  or  other  of  two  possible  causes.  The 
first  of  those  is  a  very  considerable  increase  in  the  amount  of  joint  fluid, 
actually  forcing  the  joint  surfaces  into  an  abnormal  position.  It  has  been 
shown  experimentally  that  when  the  hip-joint  has  been  filled  with  fluid 
under  pressure  the  limb  automatically  takes  up  a  position  of  abduction, 
flexion  and  external  rotation.  The  second  factor  is  one  which  is  found 
comparativel}'  late  in  the  course  of  the  disease,  and  it  is  a  considerable 
alteration  in  the  architecture  of  the  bones  which  enter  into  the  formation 
of  the  joint.  According  to  the  positions  and  the  degree  of  bone  destruction, 
a  great  variety  of  abnormal  postures  may  be  demonstrated. 

Pain. — Pain  is  the  feature  which  one  generally  associates  with 
joint  disease,  and  as  a  rule  it  is  one  of  considerable  prominence.  Why 
should  pain  occur  ?  The  reasons  differ  according  to  the  extent  of  the  dis- 
ease. In  the  early  stages  it  is  due  to  intra-articular  tension  and  pressm'e. 
The  tension  is  exerted  upon  the  synovial  membrane  and  the  joint  surface 
as  a  whole,  or  it  is  borne  by  the  articular  cartilage.  In  the  first  instance  it 
is  partly  tlie  result  of  a  thickened  synovial  membrane  and  partly  an  increased 
amount  of  fluid  within  the  joint.  In  the  second  instance  it  is  the  sequel  to 
a  subchondral  infiltration  of  the  disease,  spreading  between  the  articular 
cartilage  and  the  underlying  bone,  and  exerting  pressure  upon  both  these 
structures. 

In  the  late  stages  of  the  disease  ])ain  is  the  result  of  a  varying  degree 
of  disorganisation  within  the  joint,  a  destruction  of  the  articular  cartilages, 
and  an  exposure  of  the  osseous  surfaces. 

Not  only  is  the  pain  variable  in  its  cause,  but  it  is  also  variable  in  degree. 
Sometimes  it  is  agonising,  and  accompanied  by  general  symptoms  of  con- 
siderable acuteness ;  at  other  times  it  may  be  slight,  and  even  completely 
absent.     It  is  increased  By  movements  of  the  joint  surfaces. 

The  site  of  the  pain  is  also  hable  to  change.  Generally  it  is  local  in  the 
affected  joint.  Occasionally  it  is  referred  to  the  distribution  of  a  nerve 
trunk  lying  in  relation  to  the  diseased  joint.  The  best  example  of  referred 
pain  is  found  in  tuberculous  disease  of  the  hip-joint,  when  the  pain  is  often 
referred  to  the  front  and  the  inHer  side  of  the  knee,  following  the  distribution 
of  till'  ant(uior  crural  a!id  the  oliturator  nerves. 

Night  Cries.  -Tiiey  arc  usually  considered  as  constituting  a  special 
variety  of  pain.  They  indicate  an  extension  of  the  disease  to  the  under- 
lying bone,  and  (licir  occurrence  is  evidence  of  ulceration  of  the  articular 


48  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

cartilages.  During  sleep  the  relaxed  muscles  permit  the  diseased  surfaces 
to  come  into  contact  with  each  other  ;  pain  is  at  once  induced,  and  the 
alarmed  muscles  contract.  Their  contraction  is  intended  to  fix  the  opposed 
surfaces,  but  before  fixation  is  complete  there  is  a  momentary  increase  of 
pain.  In  some  instances  the  pain  is  not  suflicient  to  wake  the  patient,  he 
is  merely  restless  and  may  moan  in  his  sleep.  In  other  cases  the  pain  is 
so  severe  as  to  waken  the  child  with  a  start.  Sometimes  he  wakens  to  find 
the  pain  gone,  and  cannot  tell  what  disturbed  him,  sometimes  it  remains 
after  consciousness  is  complete. 

Tenderness  and  Increased  Temperature.— When  the  diseased  joint 
is  palpated  tenderness  may  be  induced.  The  handling  may  increase  the 
intra-articular  tension,  it  may  j)ress  upon  some  disorganised  constituent  of 
the  joint,  or  it  may  irritate  some  periarticular  structure  (a  bursa)  which  has 
shared  in  the  joint  inflammation.  It  is  not  a  constant  feature,  and  one 
should  not  be  inclined  to  insist  on  its  demonstration.  If  the  joint  is 
superficial,  and  the  skin  temperature  be  compared  with  that  of  the  healthy 
joint,  it  is  often  found  to  be  appreciably  elevated.  The  raised  temperature 
is  the  result  of  an  increased  vascularity  secondary  to  the  intra-articular 
changes. 

Muscular  Rigidity. — Nature  provides  the  key  to  the  treatment  of 
tuberculous  joint  disease  by  her  continual  efforts  to  keep  the  diseased  part 
at  rest,  and  the  medium  which  she  employs  is  a  muscular  one.  Intra-articular 
disease  reflexly  produces  a  rigidity  of  the  muscles  which  normally  move  the 
joint.  The  degree  of  muscular  spasm  varies  ;  it  may  be  induced  only  by 
extreme  degrees  in  the  arc  of  possible  movement ;  it  may  be  so  intense  as 
to  simulate  ankylosis.  The  degree  of  rigidity  is  probably  an  indication  of 
the  amount  and  also  of  the  position  of  the  disease.  The  cause  of  the  spasm 
is  twofold.  It  is  reflex  from  the  intra-articular  changes,  and  it  is  voluntary 
on  the  part  of  the  patient  to  prevent  friction  of  the  diseased  articular  sur- 
faces. Clinically  it  may  be  manifested  on  the  slightest  palpation,  or  it  may 
require  some  degree  of  movement  to  demonstrate  it.  It  is  characterised 
by  a  most  distinctive  sudden  contraction  of  the  surrounding  muscles. 

Swelling". — In  the  more  superflcial  joints  swelling  is  a  prominent 
feature.  Its  origin  may  be  twofold  ;  it  may  depend  on  a  tuberculous 
thickening  of  the  synovial  membrane,  or  it  may  be  the  result  of  the  distension 
of  the  joint  cavity  with  fluid.  When  the  synovial  membrane  is  responsible 
for  the  enlargement,  the  thickening  corresponds  exactly  to  its  anatomical 
distribution,  and  the  thickening  being  most  marked  at  the  synovial  re- 
flexion, the  swelling  is  noticed  more  especially  at  the  periphery  of  the  joint. 
To  palpation  a  synovial  thickening  is  characteristically  doughy.  When 
there  is  free  fluid  in  the  joint  the  sweUing  is  a  uniform  distension  of  the 
joint  capsule,  and  fluctuation  can  of  course  be  elicited. 

In  estimating  the  degree  of  swelling  in  a  tuberculous  joint  one  must 
take  into  consideration  the  muscular  wasting  which  exists  around  the  joint. 
By  comparison  a  swelling  which  is  actually  slight  may  appear  very  con- 
siderable. 


THE  CLINICAL  FEATURES  OF  JOINT  TUBERCULOSIS      49 

The  skin  over  a  diseased  joint  often  loses  its  natural  hue,  and  acquires 
an  anaemic  and  sodden  appearance.  The  superficial  veins  may  be  distended. 
If  the  disease  has  spread  from  the  joint  into  the  neighbouring  bone  there 
may  be  some  degree  of  osseous  thickening. 

Muscular  Wasting". — Early  atrophy  of  the  muscles  aroimd  the  diseased 
joint  is  a  constant  sign.  It  is  partly  the  result  of  disease  and  partly  the 
result  of  a  reflex  impulse  which  originates  within  the  joint.  Accompanying 
the  atrophy  there  is  a  diminution  in  the  reaction  to  the  faradic  current, 
and  the  tendon  reflexes  around  the  joint  are  frequently  diminished.  The 
atrophy  extends  beyond  the  muscles,  the  bones  become  rarefied,  and  growth 
may  be  interfered  with.  In  old-standmg  cases  the  degree  of  muscular 
wasting  may  give  an  exaggerated  importance  to  the  amount  of  joint  thicken- 
ing which  is  present. 

Alteration  in  Bony  Outlines. — As  the  joint  disease  progresses,  there 
sooner  or  later  ensues  a  destruction  of  the  joint  surfaces  and  of  the  under- 
lying bones.  Such  a  destruction  may  be  responsible  for  an  actual  alteration 
in  the  outline  of  the  joint,  or  it  may  induce  simple  shortening.  In  joints 
sueh  as  the  hip,  where  the  arrangement  of  the  bones  is  irregular,  the  destruc- 
tion may  give  rise  to  such  deformities  as  abduction  or  adduction.  There 
are  cases  in  which  the  joint  is  infected  secondary  to  a  bone  focus,  and  in 
such  cases  the  destruction  of  bones  is  probably  more  extensive,  and  the 
alteration  in  the  outline  correspondingly  prominent. 

Abscess  Formation. — The  abscess  formation  which  occurs  may  appear 
in  three  different  regions  :  it  may  be  piirely  intra-articular — a  type  which 
is  sometimes  designated  empyema  of  the  joint ;  it  may  be  periarticular, 
being  more  exactly  situated  outside  the  capsule  opposite  the  synovial 
reflexion  ;  finally,  it  may  be  superficially  in  relation  to  any  part  of  the 
joint.  And  as  there  arc  three  positions  of  occurrence  one  finds  that  in  each 
instance  the  etiology  varies.  The  intra-articular  abscess  is  the  result  of  the 
conversion  of  a  simple  serous  effusion — a  hydrops  of  the  joint — into  a  puru- 
lent fluid,  or  it  owes  its  origin  to  the  eruption  of  a  bone  focus  into  the  joint. 

The  periarticular  abscess  is  in  the  majority  of  instances  located  op- 
posite the  reflexion  of  the  synovial  membrane,  and  this  peculiarity  of 
situation  oilers  the  key  to  its  exact  etiology.  From  the  synovial  ri'flexioii 
a  number  of  blood-vessels  extend  outwards,  piercing  the  capsular  ligament, 
and  spreading  into  the  surrounding  soft  tissues.  When  the  synovial  mem- 
brane becomes  diseased,  offshoots  of  tuberculous  tissue  extend  outwards 
along  the  line  of  the  vessels,  and  give  rise  to  periarticular  abscesses.  An 
intra-articular  abscess  may  become  periarticular  by  forcing  its  way  through 
a  weakened  portion  of  the  capsular  ligament. 

The  etiology  of  the  superficial  abscess  is  quite  distinctive.  It  only 
occurs  when  there  is  a  considerable  degree  of  white  swelling  in  the  sur- 
rounding tissue,  and  its  development  depends  upon  pus  formation  in  the 
(Edematous  tissue.  It  has  no  traceable  connection  with  the  diseased  joint. 
Bacteriological  examination  shows  that  these  abscesses  often  contain  a 
mixed  infection. 

4 


50  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

The  development  of  a  cold  abscess  is  always  of  serious  import,  because 
the  chances  of  mixed  infection  of  the  joint  are  considerably  increased. 

General  Features.  —  In  addition  to  these  local  changes  there  are 
general  changes.  They  are  in  every  respect  similar  to  those  which  have 
been  described  in  bone  tuberculosis,  and  there  is  no  purpose  to  be  gained 
by  their  repetition. 


THE  DIAGNOSIS  OF  BONE  TUBERCULOSIS 

The  system  of  diagnosis  includes,  or  at  least  ought  to  include,  two 
distinct  psychological  processes.  The  steps  by  which  one  comes  to  the 
decision  that  one  is  dealing  with  a  certain  recognised  condition  constitutes 
what  one  may  term  the  actual  diagnosis.  The  other  process,  the  differential 
diagnosis,  necessitates  the  recognition  and  the  exclusion  of  conditions 
resembling  the  one  under  consideration. 

The  Actual  Diag'nosis. — How  does  one  come  to  the  decision  that 
a  definite  bone  lesion  is  tuberculous  ?  The  answers  are  gleaned  from  a 
variety  of  sources,  and  they  are  best  considered  in  order  of  sequence. 

Milk  History. — In  the  examination  of  any  condition  suggestive  of  • 
tuberculous  disease,  an  interrogation  regarding  the  milk  supply  is  of  the 
utmost  importance.  The  assertion  that  the  child  has  been  breast-fed  does 
not  dispose  of  the  possibility  of  infection  by  this  source  ;  for,  except  in  very 
young  children,  cows'  milk  is  almost  certain  to  have  been  administered  at 
some  period.  Two  lines  of  further  investigation  must  be  followed.  Has 
the  milk  which  the  child  receives  been  boiled  ?  Has  there  been  any  history 
of  disease  among  the  herd  from  which  the  milk  was  supplied  ?  In  bone 
tuberculosis  bovine  infection  is  a  most  fertile  source,  and  no  investigation 
is  complete  in  which  these  questions  have  been  omitted. 

Family  History. — Elsewhere  the  question  of  heredity  in  application 
to  tuberculosis  has  been  discussed.  Of  the  importance  of  an  inherited  pre- 
disposition to  infection  no  doubt  can  be  entertained.  But  the  occurrence 
of  a  tuberculous  family  history  has  a  bearing  even  more  important  than  that 
of  inherited  predisposition,  for  it  may  provide  a  fertile  source  of  direct 
infection.  A  child  residing  in  the  house  of  a  tuberculous  father  or  mother 
may  develop  tubercle  by  direct  infection  from  the  parent.  Some  time 
ago  the  writer  investigated  a  series  of  cases  of  bone  tuberculosis  from 
which  the  human  bacillus  had  been  isolated.  In  71  per  cent  of  these 
cases  there  was  a  history  of  the  child  having  been  in  residence  with 
a  consumptive. 

Age. — While  tuberculosis  of  bones  may  occur  at  any  age,  its  incidence 
is  greatest  during  childhood,  and  more  especially  between  the  ages  of  five 
to  twelve  years.  During  the  first  year  of  life  bone  lesions  are  rare.  After 
the  first  year  they  become  increasingly  common,  and  reach  their  acme 
about  ten  years. 


THE  DIAGNOSIS  OF  BONE  TUBERCULOSIS  51 

Position  of  Lesion. — In  disease  of  the  long  bones  tubercle  has  a  predilec- 
tion for  the  ends  of  the  bones,  the  metaphysis  or  the  epiphysis.  In  this 
respect  it  resembles  acute  osteomyeUtis,  and  differs  from  specific  disease, 
except  the  epiphysitis  of  congenital  syphihs.  A  certain  proportion  of  cases 
develop  in  the  centre  of  the  shaft,  the  situation  favoured  by  syphihs.  Not 
only  has  the  disease  a  partiality  for  certain  situations  in  the  bone,  but  some 
bones  are  more  liable  to  the  disease  than  others.  The  vertebrae  are  the  most 
common  to  be  affected,  and  the  short  bones  of  the  hands  and  feet  are 
frequently  diseased. 

Symptomnlologi/. — If  one  were  asked  to  mention  the  characteristic 
which  distinguishes  the  clinical  features  of  tuberculous  bone  disease,  one 
would  have  no  hesitation  in  giving  first  place  to  its  insidiousness.  Every- 
thing favours  a  gradual  development.  The  bone  is  often  deeply  situated 
and  protected  by  soft  parts,  its  particiilarly  dense  structure  is  difficult  of 
destruction  and  invasion,  and  there  can  be  no  doubt  that  the  disease  is  more 
chronic  in  this  situation  than  in  many  others.  The  general  symptoms 
which  are  common  to  tubercle  in  any  situation  may  be  of  extreme  value  in 
the  diagnosis  of  a  doubtful  case. 

Plu/sical  Signs. — Of  the  physical  signs  which  may  appear,  thickening 
and  abscess  formation  are  certainly  the  most  imjiortant.  The  thickening 
from  the  deposit  of  new  subperiosteal  bone  is  an  early  sign,  the  abscess 
formation  is  late.  To  the  occurrence  of  pain  one  does  not  attach  much 
importance  ;   frequently  it  is  entirely  absent. 

X-Ray  Examination. — While  one  may  come  to  a  definite  diagnosis  of 
bone  tubercle  from  a  consideration  of  the  several  above-mentioned  points, 
the  reasoning  is  not  complete  until  an  X-ray  photograpli  of  the  part  has 
been  taken.  A  good  negative  gives  information  on  the  following  points.  It 
tells  one  that  tlie  condition  under  examination  is  tuberculous,  it  delineates 
exactly  the  situation  of  the  disease,  and  it  affords  information  as  to  the 
exact  type  of  the  tuberculous  disease,  whether  it  is  encysted,  infiltrating, 
etc.     Full  details  are  given  of  the  various  X-ray  features  (page  58). 

Tuberculin  Tests.  No  discussion  upon  general  diagnosis  is  complete 
without  making  mention  of  certain  well-known  tuberculin  tests.  Space 
does  not  jjermit  of  more  than  a  few  remarks  about  the  various  methods. 

Calnietfe's  Ophlluilnio-Tiibercvlin  Heart  ion  .^  -  AW  the  tuberculin  tests 
depend  upon  a  heightened  susceptibility  on  the  ])art  of  the  tuberculous 
to  the  poison  of  the  tubercle  bacillus.  Tlie  increased  suscejitibility  shows 
itself  partly  by  a  general  disturbance,  malaise,  and  fever,  and  partly  by  a 
local  disturbance,  the  result  of  increased  hyperacmia  of  the  tuberculous  focus 
or  the  point  of  inoculation.  The  oplithalmic  reaction  consists  in  the  instilla- 
tion into  the  eye  of  a  drop  of  tuberculin,  either  one-half  per  cent  tuberculin 
prepared  from  the  precipitate  of  Koch's  old  tuberculin  by  95  per  cent  alcohol, 
or  a  standard  solution  prepared  by  dissolving  old  tubercidin  in  O-.*^  p(>r 
cent  phenol,  'i'lie  reaction  begins  in  six  hours,  and  it  is  fully  devel()[)ed  in 
twenty-four.     It  consists  in  a  varying  degree  of  simple  conjunctivitis.     Tln' 

'  Triiii.i.  Sirlli  hitrniiil.  Congress  Tuber.,  Washington,  1!K)8.  vol.  ii.  so(n.  iii.iv.  pp.  642-681. 


52  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

inflammation  lasts  several  days,  occasionally  weeks.  The  test  must  never 
be  applied  in  cases  of  disease  of  the  cornea  or  conjunctiva,  as  in  such  cases 
it  is  apt  to  lead  to  severe  inflammation,  ulceration,  and  even  perforation  of 
the  cornea. 

The  Cutaneous  Tuberculin  Reaction  (von  Pirquet).^ — This  consists  in  a 
skin  vaccination  with  tuberculin.  The  reagent  employed  is  composed  of 
tuberculin  1  part,  normal  saUne  3  parts,  containing  25  per  cent  carboUc 
acid.  Two  small  abrasions  are  made  upon  the  cleansed  upper  arm.  The 
abrasions  must  not  be  deep  enough  to  draw  blood.  Into  one  a  drop  of  the 
tuberculin  solution  is  rubbed,  the  other  is  kept  as  a  control.  If  tuberculous 
disease  is  present  the  infected  abrasion  shows  within  twenty-four  hours  a 
reactionary  redness  ;   this  may  pass  on  to  actual  papule  formation. 

Mora's  Test.^ — This  is  really  a  modification  of  the  cutaneous  von 
Pirquet  test.  It  consists  in  rubbing  into  the  skin  a  preparation  of  5  per 
cent  old  tuberculin  in  lanoline.  A  reaction  appears  in  the  region  into  which 
the  ointment  has  been  rubbed. 

The  Focal  Reaction  Test. — The  three  tests  already  mentioned  possess 
a  great  common  fault ;  positive  results  are  given  by  tuberculous  disease  in 
any  part  of  the  body,  and  the  presence  of  a  reaction  does  not  necessarily 
mean  that  the  lesion  under  examination  is  the  tuberculous  one.  The  local 
reaction  test  does  not  possess  this  disadvantage.  It  is  a  clinical  test,  and 
it  consists  in  the  injection  into  any  part  of  the  body  of  a  small  dose  of  tuber- 
cuhn.  If  the  lesion  is  a  tuberculous  one,  it  becomes  congested  and  hyper- 
aemic,  and  there  are  constitutional  signs  such  as  malaise,  headache,  and 
rise  of  temperature.  The  amount  of  tuberculin  injected  varies.  A  useful 
standard  is  -1  milHgramme  in  children  and  -2  milligramme  in  adults.  In 
Germany  it  is  customary  to  begin  with  an  injection  in  children  of  •!  milli- 
gramme. If  no  reaction  results  the  injection  is  repeated  with  2-5  milH- 
grammes,  and  if  there  is  still  no  reaction  with  5  milligrammes.  In  using  this 
method  it  must  be  remembered  that  susceptibility  to  tuberculin  increases 
with  each  injection,  so  that  even  the  healthy  may  react  to  large  doses.  With 
a  focal  reaction,  however,  the  possibility  of  this  error  is  diminished.  In 
doubtful  bone  cases  this  is  certainly  the  most  reUable  test.  Take,  for 
example,  a  swelling  of  the  tibia.  A  study  of  history,  symptoms,  and  physical 
signs  leaves  the  diagnosis  obscure.  X-rays  may  not  be  available.  The 
injection  of  -1  milligramme  of  tuberculin  is  followed  in  the  twenty-four 
hours  by  increased  pain  in  the  doubtful  part,  swelling,  cedema,  tenderness, 
and  redness  of  the  overlying  skin,  if  the  condition  is  a  tuberculous  one. 

The  test  is  not  without  its  disadvantages.  The  focal  reaction  has  been 
blamed  for  causing  a  dissemination  of  the  disease,  and  the  use  of  the  test 
is  absolutely  contra-indicated  in  conditions  of  fever. 

The  Diagnostic  Use  of  the  Tuberculo-Opsonic  Determination. — A  con- 
sideration of  the  facts  embodied  under  this  test  is  admirably  given  by 

'   Wien.    klin.    Wochenschr.,   Oct.    I,    1908,   s.    1375;    "Die   kutane   Tiiberkulinprobe," 
Oesellschaft  KinderheAlk.,  Dresden,  1907. 

^  MilTich.  med.  Woclienschr.,  Feb.  4,  1908. 


THE  DIAGNOSIS  OF  BONE  TUBERCULOSIS  53 

Riviere.^  One  presupposes  a  knowledge  of  the  details  of  the  opsonic 
estimation  and  its  principles.  The  application  of  the  results  is  summed 
up  by  Riviere  as  follows  : 

(1)  The  index  for  normal  people  is  found  to  vary  between  0-8  and  1-2 
(Bulloch).  When  the  index  is  persistently  below  this,  if  there  is  a  localised 
infection  which  may  be  tuberculous,  it  probably  is  so.  When  the  index 
remains  normal  it  is  not  tubercle  ;  when  it  is  high,  and  especially  when  it 
fluctuates  from  time  to  time,  there  is  active  tuberculosis. 

(2)  The  effect  of  a  small  dose  of  tuberculin  on  the  opsonic  index  is  of 
diagnostic  value.  In  the  tuberculous  it  leads  to  a  negative  phase,  followed 
by  a  positive  phase.  The  negative  phase  is  absent  in  non-tuberculous 
subjects. 

(3)  When  the  local  lesion  contains  fluid  (abscess)  the  bacteriotropic 
power  of  the  fluid  is  lowered  towards  the  organism  causing  the  lesion,  i.e. 
the  opsonic  index  of  the  fluid  is  found  to  be  lower  than  that  of  the  patient's 
blood  serum. 

(4)  The  "  heated  serum  test "  depends  on  the  fact  that  the  serum  of 
the  tuberculous  and  tuberculinised  retains  more  of  its  opsonic  power  after 
heating  to  60"^  C.  for  ten  minutes  than  does  normal  serum.  The  tuberculo- 
opsonic  determination  has  little  use  in  clinical  application. 

Differential  Diag'nosis. — There  are  certain  conditions  which  require 
to  be  differentiated  from  tuberculous  disease,  and  confusion  is  more  apt  to 
occur  before  the  stage  of  abscess  formation. 

Syphilis,  Periostitis  and  Periosteal  Nodes,  and  more  especially  Gummala 
and  Sclerosing  Osteitis. — These  are  excluded  by  the  history  of  syphihs, 
congenital  or  acquired,  by  the  specific  intensity  of  the  pain  during  the 
night,  by  the  affection  occurring  usually  about  the  middle  of  the  shaft,  by 
the  X-ray  appearance,  and  by  the  result  of  the  Wassermann  reaction. 

Chronic  Staphylococcal  Osteomyelitis. — In  this  condition  the  onset  has 
characters  which  betray  the  acuteness ;  its  course  is  curiously  liable  to 
exacerbation  and  interval  relapses,  there  are  frequently  considerable  rises  of 
temperature,  there  are  often  signs  of  local  inflammation,  oedema,  and  tender- 
ness. An  X-ray  examination  may  be  of  value,  but  frequently  the  radio- 
graphic appearance  closely  resembles  that  shown  in  tuberculosis.  The  dis- 
tinguishing points  are,  that  in  the  subacute  condition  the  deposit  of  new 
subperiosteal  bone  is  scanty  and  incomplete,  and  sequestrum  formation  is 
more  common. 

Subperiosteal  Lipoma. — The  mistake  is  made  of  confusing  this  with 
a  subperiosteal  cold  abscess,  and  therefore  assuming  the  presence  of  under- 
lying tuberculous-disease.  The  condition  is  recognised  by  the  entire  absence 
of  bone  thickening,  the  limitation  and  slowness  of  the  disease,  and  the 
X-ray  appearances  of  a  healthy  bone. 

Periosteal  Sarcoma. ~Th\s  condition  is  the  most  dillicult  to  distinguish. 
It  may  usually,  however,  be  recognised  by  the  rapidity  of  its  growth,  the 
severity  and  the  persistence  of  pain,  and  tlie  entire  absence  of  suppuration. 

'  Hivierp,  Tiihernilnsi.1  in  I njinnij  and  Cliitdliood,  Kolynack,  1908,  ji.  2S3. 


54  TUBERCULOSIS  OF  THE  BONES  AXD  JOINTS 

X-ray  examination  affords  the  most  powerful  diagnostic  aid.  In  periosteal 
sarcoma  there  is  the  formation  of  new  periosteal  bone,  but  the  line  of  junction 
between  the  new  bone  and  the  original  shaft  is  irregular  and  eroded.  In 
tuberculous  disease  the  junction  between  old  and  new  bone  is  sharply 
defined  and  clear  cut.  In  exceptional  cases  an  exploratory  inicsion  may 
be  required  to  clear  up  the  diagnosis. 

Central  Sarcoma. — Rarely  this  may  be  confused  with  central  tubercu- 
lous disease.  Its  distinctions  are  the  rapidity  of  its  growth,  the  persistence 
of  pain,  the  umform  character  of  the  swelling,  the  presence  of  "  egg-shell  " 
crackling,  and  the  distinctive  X-ray  appearance  of  a  central  growth  expand- 
ing the  outer  shell  of  bone. 


THE  DIAGNOSIS  OF  JOINT  TUBERCULOSIS 

Actual  Diagnosis. — Many  of  the  remarks  made  in  the  section  on 
the  diagnosis  of  bone  disease  may  be  applied  to  jomt  disease.  There  is 
nothing  further  to  be  said  upon  the  questions  of  age,  family  history,  and 
milk  history.     In  joints,  as  in  bones,  these  facts  are  of  immense  importance. 

Symptomatology  and  Physical  Sig7is. — There  are  certain  of  the  signs 
of  joint  disease  which  are  important  because  they  are  vinicpie,  and  therefore 
their  value  in  diagnosis  is  correspondingly  great.  The  three  features  to 
which  one  would  apply  the  term  unique  are  those  of  synovial  thickening, 
muscular  wasting,  and  night  pains.  The  distinctiveness  of  each  may  be 
questioned,  but  closer  examination  will  show  how  characteristic  each  may 
be.  Synovial  thickening  may  occur  in  other  diseases,  e.g.  in  syphilitic 
synovitis,  but  in  tubercle  there  are  two  features  which  are  pathognomonic, 
the  uniform  outline  of  the  swelling  delimiting  the  synovial  membrane,  and 
the  doughy  sensation  on  palpation.  Muscidar  wasting  occurs  in  the  neigh- 
bourhood of  any  joint  when  the  part  is  kept  at  rest,  but  the  wasting  in 
tuberculous  disease  is  much  more  rapid  and  excessive  than  in  any  form  of 
disease  atrophy.  Night  pains  owe  their  origin  to  destruction  of  the  articular 
cartilage,  and  the  cartilage  may  be  destroyed  in  a  variety  of  conditions  ; 
but  the  night  cries  of  tubercle  are  characterised  by  their  gradual  onset 
and  the  relief  afforded  them  by  extension.  The  alterations  in  the  use  and 
position  of  the  joint,  while  not  unique,  are  exceedingly  suggestive.  The 
alteration  in  use  is  so  gradual  that  the  patient  may  be  unconscious  of  it 
until  his  attention  is  directed  towards  it.  Abscess  formation  is  quite  dis- 
tinctive of  the  disease,  but  it  would  be  well  that  a  diagnosis  be  made  before 
the  disease  had  progressed  so  far.  Muscular  rigidity  is  important.  It  is 
essential  to  recognise  that  the  fixation  on  account  of  the  rigidity  need  not 
necessarily  be  complete,  it  may  consist  in  a  limitation  of  complete  move- 
ment, but  one  attaches  great  weight  to  the  fact  that  every  movement  of 
which  the  joint  is  capable  is  more  or  less  affected. 

General  Tests. — These  have  been  fullv  dealt  with  in  the  diagnosis  of 


THE  DIAGNOSIS  OF  JOINT  TUBERCULOSIS  55 

bone  disease.  In  application  to  joints  the  foc^l  reaction  following  the 
inoculation  of  a  small  quantity  of  tuberculin  is  certainly  the  most  reliable. 
A  tuberculous  joint  becomes  characteristically  altered  by  increased  pain, 
rigidity,  and  swelling. 

X-Raij  Examination. — Any  doubt  in  diagnosis  which  a  clinical  study 
may  leave  is  usually  cleared  up  by  X-ray  examination.  In  the  later  stages 
of  the  disease  the  recognition  of  a  tuberculous  joint  is  an  easy  matter,  the 
difficulty  lies  in  the  early  stages.  The  appearances  are  hereafter  described. 
The  earliest  is  the  indistinctness  and  blurring  of  the  bone  ends,  an  impres- 
sion which  is  partly  the  result  of  the  synovial  thickening  and  partly  of  the 
increased  vascularity  of  the  membrane.  \\Tien  the  cartilage  edges  become 
eaten  out  and  their  deep  surface  undermined,  recognition  is  simplified.  In 
the  later  stages  of  the  disease  no  mistake  can  be  made. 

Differential  Diagrnosis. — There  are  a  number  of  conditions  which 
may  increase  the  possibility  of  doubt  and  error  ;  the  following  are  the  most 
important. 

Traumatic  Sipiovitis. — When  a  synovial  effusion  quickly  follows  on 
an  injury  such  as  a  sprain,  or  on  overuse  or  any  form  of  internal  derange- 
ment of  the  joint,  it  is  a  case  of  traumatic  synovitis.  In  typical  cases, 
seen  soon  after  the  injury,  there  is  not  much  possibility  of  confusing  the 
condition  with  tubercle,  but  if  the  case  is  seen  some  time  after  its  onset 
there  may  be  doubt.  The  synovial  membrane  may  remain  thickened  after 
a  traumatic  synovitis,  more  especially  if  the  traumatism  has  been  recurrent. 
A  distinction  may  be  made  by  the  history  and  the  progressive  nature  of  the 
tuberculous  disease. 

Infective  Synovitis  and  Arthritis. — These  diseases  are  characterised  by 
more  or  less  rapid  and  abundant  effusion  of  fluid  into  the  joint ;  in  children 
they  are  pneumococcal,  staphylococcal,  or  streptococcal  in  origin.  In  their 
early  stages  it  may  be  impossible  to  distinguish  them  from  tuberculous 
disease,  but  they  quickly  become  recognisable  by  their  sudden  onset,  the 
gravity  of  the  general  illness,  and  the  tendency  to  pass  on  quickly  to  sup- 
puration. Sonietimes  a  study  of  age  is  helpful;  these  acute  joint  conditions 
are  most  conunonly  met  with  during  the  first  year  of  life,  a  period  when 
tubercle  is  comparatively  rare. 

Epiphi/sitis  and  Osteitis  in  the  Neiffhbniirhnnd  of  the  Joint.  A  neighbour- 
ing bone  focus  may  produce  a  reflex  joint  effusion,  and  in  this  way  a  possi- 
bility of  error  may  arise.  The  symptoms,  however,  are  always  in  some 
degree  acute,  there  is  considerable  swelling,  and  the  temperature  is  con- 
tinuously high.  Early  recognition  of  the  condition  is  important  on  account 
of  the  ever-present  tendency  towards  invasion  of  the  joint. 

Periarticiihir  Bursitis.  Many  joints  are  intimately  related  to  over- 
lying bursx>,  and  lesions  of  the  bursa;  may  produce  considerable  similarity 
to  tuberculous  disease.  This  is  well  illustrated  in  the  hip-joint,  when  dis- 
ease of  the  bursa  beneath  the  {.'liiteus  inaxinnis,  or  that  lying  in  relation 
to  the  psoas,  may  very  closely  simulate  hip-joint  disease.  In  bursitis,  iiow- 
ever,  there  is  an  absence  of  the  characteristic  signs  of  joint  disease — the 


56  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

synovial  thickening,  the  muscular  wasting,  and  the  night  cries.  In  the 
presence  of  further  doubt  an  X-ray  examination  will  clear  up  the  point. 

Syphilitic  Joint  Disease. — In  application  to  children  one  need  only 
consider  the  jomt  lesions  of  hereditary  syphilis.  The  earUest  are  those 
associated  with  an  epiphysitis  in  the  ends  of  the  bones.  The  condition 
occurs  in  infants,  usually  between  the  fourth  and  twelfth  weeks  of  hfe,  and 
the  joint  effusion  is  a  simple  serous  one.  The  age  of  the  child  and  other 
evidences  of  syphilis  are  sufficient  to  exclude  the  condition. 

The  gummatous  synovitis  of  older  children  may  give  rise  to  great 
difficulty  in  diagnosis  ;  it  has,  however,  certain  distinctive  features,  and  they 
are  its  insidious  development,  the  absence  of  constitutional  disturbances,  the 
bilateral  character  of  the  disease,  the  tendency  for  the  knee-joints  to  be 
most  commonly  affected,  the  absence  of  pain,  and  the  presence  of  free 
mobility. 

Rheumatoid  Arthritis  or  Osteoarthritis. — This  has  occasionally  been 
confused  with  tuberculous  disease.  Its  occurrence  in  children  is  rare,  but 
when  it  is  met  with  it  may  be  recognised  by  the  bony  changes  which  are 
present  and  the  polyarthritic  character  of  the  disease. 

Still's  Disease  of  the  Joints. — The  possibility  of  confusion  is  more  prob- 
able in  this  disease  than  in  rheumatoid  arthritis.  It  resembles  tubercle  in 
so  far  as  the  synovial  membrane  is  thickened  and  pulpy.  The  joints  in  the 
later  stages  become  stiffened,  simulating  rigidity,  and  there  is  marked 
muscular  wasting.  It  differs  from  tuberculous  disease  in  being  a  poly- 
arthritis, in  being  free  from  pain  and  true  muscular  rigidity,  and  in  being 
associated  with  an  enlargement  of  the  spleen  and  the  lymphatic  glands. 

Infantile  Paralysis. — With  the  onset  of  anterior  poliomyeUtis  there  may 
be  for  a  short  time  marked  pain  and  tenderness,  with  immobility  of  the 
joint.  The  acute  changes  quickly  subside,  and  the  paralytic  phenomena 
become  obvious. 

Hysterical  Joint  Affections. — In  nervous  children,  dming  the  period  of 
hfe  immediately  before  puberty,  a  condition  of  joint  sensitiveness  with 
lameness  and  pain  is  observed.  If  functional,  these  features  may  be  recog- 
nised by  the  variabihty  of  their  intensity  and  their  inconsistency  with  one 
another. 

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Melchior,  E.     "  Die  tuberkulose  Gelenkrheumatismus,"  Centralis,  j.  d.  Grenzgeh.  d.  Med. 

und  Chir.,  Jena,  1909,  xii.  801-818. 
C.u,DWELL,  C.  B.     "  Diagnosis  in  Suspected  Joint  Disease,"  Lancet  Clinic,  Cincinnati,  1909, 

cii.  448-451. 
O'Reilly,  A.     "  A  Pica  for  an  Early  and  more  Complete  Diagnosis  in  .Joint  Tuberculosis  in 

Children,"  J.  Miss.  Med,  Assoc.,  St.  Louis,  1909-10,  vi.  615-623. 
Bredi,  C.  S.    "  The  Early  Diagnosis  of  Tuberculosis  of  the  Bone,"  West.  Med.  Review,  Omaha, 

1910,  XV.  70-75. 
Horwitz,  a.  E.     "  Differential  Points  in  the  Character  of  the  Bone  Lesion  in  Tuberculous 

and  Acute  Osteomyelitis,  Rachitis,  and  Syphilis,"  Weekly  Bull.,  St.  Louis  Med.  Soc, 

1910,  iv.  162. 
Privat,  T.     "  Tulierculose  externe,  syphilis  et  scrofulate  de  vcrole,  diagnostic  et  traitement," 

Sev.  gen.  de  din.  et  de  therap.,  Paris.  1910,  xxiv.  249-231. 
Mehans.     "  Die  Rollc  dcr  isolierten  Muskclatropie  als  diagnostisches  Symptom  zu  Lokalisa- 

tion  von  tubcrkuhison  Knochenhcrdcn,"  Zentrnlbt.  fiir  Chir.,  Leipzig,  1910,  xxxvii.  8.52. 
OoiLVV,  C.     "  The  Early  Diagnosis  of  Tuberculous  Joint  Disease,"  Post  Graduate,  New  York, 

1910,  XXV.  60-06. 
Holmer,  B.     "Diagnosis  and  Treatment  of  Osteal  Tubercle  without  Abscess  Formation." 

Med.  Rec,  New  York,  1910,  Ixxviii.  1003-1005. 
SwETT,   P.   P.     "  The  Diagnosis  and  Treatment  of  Tuberculous  Joints,"  New   York  Med. 

Journ.,  1910.  xcii.  912-915. 
Horwitz.     "  Differential  Points  in  Bone  Lesions  in  Tuberculous  and  Acute  Osteomyelitis, 

Rickets,  and  Syphilis,"  Interstate  Med.  Jonrn.,  St.  Loui.s,  1910,  xvii.  515-520. 
Schwartz,  A.     "  Examen  d'uno  articulation  maladc,"  Progres  med.,  Paris,  1910,  '.i"  S.  xxvi. 

465. 
Brackett,  E.  0.     "The  Diagnosis  of  the  Tiilicrculous  Character  of  Joint  Disease,"  Boston 

M.  and  S.  .fourn.,  1913,  cxviii.  673-67l>. 


58  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


THE  X-RAY  APPEARANCES  IN  NEGATIVES  OF 
TUBERCULOUS  BONES 

The  Apparatus. — In  taking  a  radiograph,  the  Rontgen  or  X-ray  tube 
forms  the  most  important  part  of  the  armamentarium.  It  is  occasionally- 
possible  to  get  a  good  result  from  an  inferior  outfit  if  only  there  is  a  suitable 
tube,  but  the  best  outfit  will  be  useless  if  an  inferior  tube  is  the  only  one 
available.  The  suitability  of  a  tube  depends  upon  the  degree  of  vacuum 
within,  and  tubes  may  be  classified  into  three  groups — soft,  hard,  and 
medium. 

Soft  tubes  possess  a  low  degree  of  vacuum,  and  they  give  off  rays  of 
a  low  degree  of  penetration  ;  hard  tubes  have  a  high  degree  of  vacuum, 
and  their  rays  have  a  correspondingly  high  penetrating  power ;  medium 
tubes  strike  an  average. 

Substances  are  penetrated  by  X-rays  in  relation  to  (1)  their  atomic 
weight,  (2)  their  thickness.  The  greater  the  atomic  weight  and  the  thick- 
ness the  harder  must  be  the  ray  in  order  to  penetrate.  It  will  therefore  be 
understood  why,  in  taking  a  radiograph  of  such  a  superficial  part  as  the 
hand,  one  chooses  a  soft  tube,  and  in  deeply  placed  bones — femur  and  pelvis 
— a  hard  tube  is  to  be  preferred. 

The  Reading-  of  the  Radiog-raph.— The  X-ray  plate  ^  may  be  looked 
at  from  the  glass  or  from  the  film  side.  If  observations  are  made  from  the 
film  side  there  is  the  advantage  that  the  observer's  eye  occupies  the  position 
of  the  X-ray  tube,  but  it  must  be  remembered  that  the  positions  are  reversed, 
and  the  right  hand  of  the  observer  corresponds  to  the  left  hand  of  the  nega- 
tive. In  studying  the  negative  from  the  glass  side,  the  observer  may  imagine 
that  he  is  looking  at  the  part  from  behind,  and  the  sides  of  observer  and 
plate  correspond.  It  is  an  advantage  to  examine  the  plate  in  an  illumin- 
ating box.     A  diffuse  light  which  can  be  varied  in  intensity  is  the  best. 

Normal  X-Ray  Appearance  of  Bone. — In  a  good  X-ray  considerable 
anatomical  detail  is  shown.  The  periosteum  is  visible  as  a  faint  clear  line, 
covering  the  surface  of  the  bone.  Beneath  it  there  is  the  compact  bone  of 
the  shaft ;  the  arrangement  of  the  lamellaB  may  be  demonstrated,  and  occa- 
sionally Haversian  systems. 

In  the  centre  of  the  bone  the  cancellous  tissue  appears  as  a  porous 
network,  the  lamellae  appearing  as  irregular  clear  lines.  Coursing  through 
the  interlamellar  spaces  blood-vessels  may  sometimes  be  made  out.     In  the 

'■  In  the  following  description  the  terms  light  and  dark  refer  to  the  appearance  of  the 
negative.  Dark  areas  in  the  plate  signify  that  the  tissue  has  been  more  permeable  to  X-rays 
than  the  surrounding  parts,  and  vice  versa. 


PLATE  XXXV.—TiiK  X-uav  Aim'Eahanck  of  kaklv  Tlbeucli.ous  Diseask  of  the  Bosk. 

In  the  under  surfftce  of  the  neck  of  tlie  femur  there  is  a  focus  of  encysteil  tuberculous  disease.  The 
riMitrc  of  tlie  focus  sliows  an  inilcfinite  c)cai'  area  which  corresponds  to  a  deposit  of  tulierculous  (iranu- 
hition  tissue.  Arouml  tlic  I'cntral  focus  tlicrc  is  a  darl<  liand  convsiioiulin);  to  an  area  of  liluous  tissue, 
whicli  as  a  soft  tissue  structure  liiis  olfered  little  obstruction  to  the  passage  of  the  rays.  Beyond  this 
d.irk  band  there  is  a  well-defined  light  l>and  which  corresponds  to  an  area  of  condensed  lamellae. 


X-RAY  APPEARANCES  OF  TUBERCULOUS  BONES  59 

growing  child  the  epiphyseal  cartilages  appear  as  clear  bands  of  varying 
depths  passing  across  the  outline  of  the  bone.  It  is  important  to  observe 
that  the  distal  surface  of  the  cartilage,  that  is,  the  surface  lying  next 
the  epiphysis,  is  smooth  in  outline,  while  the  surface  which  looks  towards 
the  shaft,  being  the  growing  surface,  is  more  irregular.  Beyond  the  epiphy- 
seal cartilage  lies  the  epiphysis.  According  to  the  age  of  the  child  it  may 
appear  structureless,  no  ossification  having  yet  developed,  it  may  show 
a  small  developing  centre  of  ossification,  or  it  may  have  a  structure  similar 
to  that  of  healthy  cancellous  bone. 

It  is  most  essential  to  have  a  definite  knowledge  of  the  normal  X-ray 
anatomy  in  order  to  appreciate  the  finer  discrepancies  of  the  diseased 
condition. 

Patholog'ical  Changes. — The  changes  will  be  described  according 
to  subdivisions  of  situation,  whether  they  occur  centrally  or  peripherally, 
within  the  cancellous  tissue  or  beneath  the  periosteum.  The  description  is 
concluded  with  a  synopsis  of  the  changes  which  one  finds  in  the  four  types 
of  bone  tubercle — the  encysted,  the  infiltrating,  the  atrophic,  and  the 
hypertrophic. 

Central  Changes. — One  rarely  has  an  opportunity  of  witnessing  the 
X-ray  appearance  of  an  early  central  disease.  The  original  marrow  tubercle 
appears  in  the  negative  as  a  rounded  light  point.  The  cellular  collection 
which  constitutes  the  tubercle  offers  an  increased  resistance  to  the  passage  of 
the  rays,  with  the  result  that  the  negative  demonstrates  its  presence  as  a 
point  of  diminished  density.  At  this  early  period  no  other  change  is  visible. 
Now  let  us  suppose  that  the  disease  is  more  extensive  and  has  come  to 
involve  a  greater  extent  of  the  bone.  The  principal  changes  are  similar. 
A  portion  in  the  medulla  of  the  bone  appears,  of  diminished  density,  and 
stands  out  from  the  negative  as  a  light  area.  But  the  changes  do  not  stop 
there  ;  there  are  characteristic  appearances  in  the  lamella?.  Those  which  lie 
within  the  light  area,  that  is  to  say,  those  which  lie  in  the  diseased  tissue, 
have  either  been  absorbed  or  are  in  process  of  absorption.  The  lameiiaa 
which  are  around  the  diseased  area  appear  wasted  and  rarefied,  a  preliminary 
in  the  process  of  absorption.  Sometimes  lamellae  which  lie  well  beyond 
the  diseased  area  ap))ear  thickened.  Then  there  are  radiographic  alterations 
in  the  marrow  between  the  lamella?.  Normally  marrow  appears  in  the 
negative  as  a  dark,  structureless  background,  from  which  the  clearer  lauiilla; 
stand  out.  For  some  distance  around  a  tuberculous  focus  one  finds  that 
the  marrow  loses  its  dark  homogeneous  character  and  becomes  lighter 
with  a  faint  striated  appearance.  The  skiagraphic  impressions  arc  con- 
comitant with  a  histological  marrow  fibrosis. 

One  would  sum  up  the  X-ray  appearances  of  a  well-defined  central 
disease  as  follows  :  An  area  in  the  medulla  of  the  bone  appears  of  diminisliod 
density,  it  corresponds  to  the  tuberculous  granulation  tissue.  Within  tiio 
light  area  the  lamella?  are  absorbed,  and  around  the  periphery  they  are 
rarefied.  There  is  an  area  well  outside  the  diseased  focus  in  which  the 
lamella;  appear  thickened.      Between  the  lamell.T,  around  the  periiihery  of 


60  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

the  central  deposit,  the  cai'ijet  of  marrow  loses  its  dark  uniform  appear- 
ance ;  it  becomes  lighter,  and  its  structure  has  a  suggestion  of  striation. 
This,  which  may  be  taken  as  the  typical  appearance,  is  altered  under  two 
conditions,  namely,  cavity  formation  and  sequestration.  AVhen  cavity 
formation  occurs  there  is  a  diminution  in  resistance  to  the  passing  rays, 
and  the  area  is  registered  as  a  dense  black  shadow,  it  may  be  in  the  centre 
of  the  light  tuberculous  area.  If  a  detached  sequestrum  is  present,  it,  as 
an  object,  offers  very  considerable  resistance  to  the  rays.  And  in  the 
skiagram  it  appears  as  an  area  somewhat  lighter  than  that  afforded  by  the 
diseased  granulation  tissue. 

Peripheral  Changes. — In  the  section  on  pathology  attention  has  been 
drawn  to  the  importance  of  new  subperiosteal  bone,  and  the  deposit  is  well 
shown  by  an  X-ray  negative.  If  a  series  of  negatives  be  examined  at 
different  stages  of  the  disease,  the  earUest  periosteal  appearance  is  the 
development  of  what  looks  like  a  space  between  the  periosteum  and  the 
underlying  bone.  In  reality  it  is  the  picture  afforded  by  the  first  stage  of 
the  deposit  of  new  subperiosteal  bone  granulation  tissue,  which  has  not  yet 
become  ossified.  At  a  later  examination  there  is  a  typical  deposit  of  pew 
bone  between  the  periosteum  and  the  underlying  shaft.  If  the  new  bone 
is  deposited  upon  the  shaft  it  is  cancellous  ;  if  it  is  laid  down  in  the  neigh- 
bourhood of  a  joint  its  thickness  is  not  so  great,  and  its  composition  is 
comparatively  denser.  In  examining  an  X-ray  negative  of  new  subperiosteal 
bone,  one  should  never  omit  to  exanxine  the  surface  of  the  underlying 
compact  bone.  In  tuberculous  disease  such  ought  to  be  smooth.  This  is 
important,  because  it  is  the  distinguishing  feature  between  the  X-ray 
appearances  of  a  periosteal  thickening,  due  to  underlying  tubercle,  and 
that  due  to  periosteal  sarcoma.  In  the  latter  the  outline  of  the  compact 
bone  is  eaten  out  and  irregular. 

The  X-Ray  Negative  Appearances  in  Special  Types 
of  Bone  Tuberculosis 

Encysted  Tubercle. — The  situation  is  usually  in  or  about  the  region 
of  the  metaphysis.  In  a  fully  developed  focus  the  appearances  are  typical. 
Standing  out  from  the  centre  of  the  bone  there  is  a  light  area,  from  which 
all  trace  of  lamellar  structure  has  been  removed.  Within  that  light  area, 
which  corresponds  to  the  actual  tuberculous  disease,  there  may  be  demon- 
strable the  dark  shadow  of  a  cavity  formation,  or  the  lighter  irregular 
appearance  of  a  sequestrum.  Around  the  periphery  of  the  focus  there  is  a 
dark,  dense  ring.  It  corresponds  to  the  encapsulating  fibrous  tissue  which 
has  locahsed  the  disease,  and  it,  as  a  soft  tissue,  offers  little  obstruction  to 
the  passage  of  the  rays.  Beyond  this  narrow  dark  band  there  is  a  broader 
and  lighter  zone,  corresjDonding  to  an  area  of  condensed  lamella?.  Some- 
times the  periosteiim  shows  no  reaction,  but  occasionally  the  picture  is 
completed  by  the  deposit  of  a  varying  amount  of  new  periosteal  bone. 

Infiltrating'  Tubercle. — This  is  the  most  difficult  type  of  tubercle 


I'LA'l'l';     XXXV'I.^THK    \-HAV    yVri'KAItANtK    OK    NKW    Sriil-KHIOSTKAL    HoNi:. 

Thf  new  lioiK'  is  sccomlarv  l<>  tul)LTrnIi»us  disi-asc  of  tin-  Hist  nu'tiitarsal  Ihhic. 


PLATE  XXXVII.— Thk  X-kav  ai'I'eaka.nck  in   Ti-beuculous  Iuseask  vt   ihe  Bone  associated 
WITH  Secjuesthum  Formation  and  a  Cavity. 


I'l.A'I'K     XX.W  Ml.       TllK    XllAV    Ali'K.VIlANC'K    OK    llvi'KllTHIll'Mlr    TOHKKCUI.OSIS    OK   TIIK   TiBIA. 

There  is  very  considunaile  hypcTostosis  of  tliu  bono  nml  a  central  sequestnim  surrouiulra  liy  an  area  of 

granulation  tissue. 


PLATE   XXXIX. — Thk  X-hay  appeabancit'op  Atrophic  Tubebcdlol's  Disease  of  the 

UITEU    END    OF   TBE    ULNA. 

Note  tlie  tliin  "glassy  "  appearance  of  tlie  boue. 


X-RAY  APPEARANCES  OF  TUBERCULOUS  BONES     61 

in  which  to  obtain  a  satisfactory  radiograph.  The  best  results  are  obtained 
by  attention  to  a  detail  in  the  technique  of  development,  and  that  detail  con- 
sists in  giving  a  long  exposure,  and  subsequently  retarding  the  development 
of  what  would  otherwise  be  a  dense  negative.  In  appearance  the  cancellous 
tissue  of  the  bone  is  occupied  by  an  irregular  light  area  corresponding  to 
the  diseased  tissue.  Within  the  clear  area  there  may  be  darker  spots  of 
cavity  formation,  there  certainly  are  lighter  points  which  represent  multiple 
minute  sequestra.  Occasionally  the  area  may  be  occupied  by  a  large 
composite  sequestrum.  The  distinctive  points  in  the  interrogation  of  the 
plate  lie  at  the  periphery  of  the  central  disease.  Here  there  is  no  limiting 
band  to  be  seen  and  no  condensation  of  lamellse.  The  periosteum  always 
reacts,  and  there  is  the  appearance  of  a  quantity  of  new  subperiosteal  bone. 

Atrophic  Tubercle. — The  X-ray  appearances  of  this  type  are  distinct- 
ive. The  outline  of  the  bone  is  enlarged,  but  it  looks  like  an  empty  shell. 
The  interior  is  clear,  here  and  there  are  traces  of  lamellae,  but  they  are 
wasted  and  thin.  There  is  a  deposit  of  new  periosteal  bone,  but  the  deposit  is 
meagre.  All  through  the  field  there  are  dark  areas  of  cavity  formation, 
there  is  nothing  suggestive  of  sequestra. 

Hypertrophic  Tubercle. — The  diseased  area  is  usually  situated  about 
the  centre  of  the  shaft.  In  examining  a  radiograph  of  the  part,  the  first 
point  to  catch  one's  attention  is  an  abnormality  in  the  nutrient  vessel. 
The  vessel  is  apparent,  which  it  ought  not  to  be,  and  it  is  thickened.  These 
changes  are  explicable  by  the  endarteritis,  which  one  knows  to  have  occurred 
pathologically.  AVithin  the  centre  of  the  bone  there  is  an  oval  dark  area, 
and  in  the  dark  area  the  impression  of  a  central  sequestrum  standing  out  in 
a  light  relief.  All  around  the  lamellse  are  hyperostosed  and  thickened. 
Finally,  it  is  most  important  to  observe  that  there  is  little  formation  of  new 
periosteal  bone,  the  thickening  is  mainly  an  endosteal  one. 

The  X-Ray  Negative  Appearances  in  Tuberculous 

Joints 

The  X-Ray  Appearance  of  a  Normal  Joint.  The  characteristic  of  a 
healthy  joint  is  its  invisibility.  The  articular  cartilages  may  be  apparent 
as  indefinite  light  lines,  covering  the  opposing  ends  of  the  bones.  The 
synovial  membrane  should  certainly  not  be  visible.  The  ligaments  often 
may  be  traced  on  a  good  negative  as  faint  light  bands,  and  the  surrounding 
tendons  and  muscles  may  often  be  similarly  demonstrable.  But  of  the 
true  joint  structure  little  or  nothing  should  ho  visible. 

The  X-Ray  Appearance  of  a  Tuberculous  Joint. — A  comprehensive 
idea  may  be  obtained  if  the  changes  are  considered  at  three  stages  in  the 
course  of  the  disease — early,  medium,  and  late. 

Earlij  Joint.  Disease. — Two  joint  structures  show  changes  in  even  the 
earliest  stages  of  joint  disease,  and  these  structures  are  the  synovial  mem- 
brane and  the  ends  of  the  bones  which  lie  within  the  synovial  reflexion. 
The  synovial  membrane,  invisible  in  a  healthy  joint,  now  becomes  visible  ; 


62  TUBERCULOSIS  OF  THE  BONES  AJSID  JOINTS 

its  distribution  can  be  traced  as  a  smoky  indefinite  band.  It  bulges  out- 
wards the  overlying  ligaments  and  muscles,  and  it  projects  into  the  interior 
of  the  joint.  The  other  distinctive  feature  lies  in  the  ends  of  the  bones. 
They  have  lost  their  clear-cut  cancellous  structure,  their  outline  is  blurred, 
shadowy,  and  indistinct. 

The  explanations  of  these  changes  are  obvious,  the  synovial  membrane 
is  thickened  because  it  has  become  diseased.  The  ends  of  the  bones  are 
indistinct  for  two  reasons,  partly  because  the  rays  require  to  pass  through 
thickened  synovial  membrane,  and  partly  because  they  penetrate  a  mem- 
brane the  vascularity  of  which  has  greatly  increased. 

Medium  Joint  Disease. — When  one  considers  the  changes  in  a  joint  in 
which  the  disease  is  more  advanced,  one  finds,  in  addition  to  the  above, 
other  features  making  their  appearance.  The  synovial  membrane  is  thick- 
ened and  the  ends  of  the  bones  are  blurred,  but  in  addition  the  articular 
cartilage  is  most  suggestively  altered.  It  is  altered  in  three  situations — 
around  its  periphery,  on  its  free  surface,  and  on  its  deep  surface.  At 
the  periphery  there  is  an  appearance  as  though  pieces  had  been  gouged  out 
from  the  cartilage  edges,  it  is  a  destruction  of  the  extremity  of  the  cartilage 
by  the  diseased  tissue  of  the  synovial  membrane.  On  the  free  surface  the 
cartilage  has  lost  its  smooth  outline,  and  has  become  irregular — the  result  of  • 
a  perichondral  ulceration.  On  the  deep  surface  the  cartilage  is  irregular, 
and  it  looks  as  though  it  had  been  lifted  off  and  separated  from  the  under- 
lying bone  ;  this  appearance  is  produced  by  the  infiltration  subchondrally 
of  a  quantity  of  diseased  granulation  tissue. 

Late  Joint  Disease. — The  X-ray  appearances  may  vary  within  wide 
limits.  All  traces  of  the  origmal  joint  outline  become  lost.  A  space  between 
the  ends  of  the  bones  is  occupied  by  a  white,  blurred  mass.  The  bone  sur- 
faces are  eroded  and  irregular,  and  within  the  bone  substance  there  are 
secondary  tuberculous  deposits,  the  radiographic  appearance  of  which  has 
been  already  described.  If  a  quantity  of  fluid  has  collected  within  the 
joint  it  will  be  noticed  that  the  articular  surfaces  are  more  widely  separated 
than  usual. 

BIBLIOGRAPHY 

Skinnek,  E.  H.       "  A  Rontgenological  Discussion  of  Bone  Lesions,"   Interstate  M.J.,  St. 

Louis,  1908,  XV.  431-438. 
DiEFFBNEACH,   W.   H.     "  Differential  Diagnosis   by  means  of   X-Rays  of  Diseases  of  the 

Osseous  System,"  Journ.  Admnced  Therap.,  New  Yorls,  1908,  xxvi.  283-296. 
EWALD,  P.     "  Fusswurzel  Tubcrculose  und  ihre  Diagnose  mittol  Rontgenstrahlen,"  Fortschr. 

a.  d.  Geb.  d.  Rontgenstrahlen,  Hamburg,  1908,  xii.  30-35. 
Granger,  A.     "  Rontgen  Rav  Diagnosis  of  the  Diseases  of  the  Bones  and  Joints,"  Journ. 

Advanced  Therap.,  New  Yorlv,  1908,  xxvi.  561-566. 
Jacobsohn,    E.     "  Die    chronischen    Gelenkerkrankungen    im    Rontgenbilde,"    Mitt.    a.   d. 

Grenzgeb.  d.  Med.  und  Chir.,  .Jena,  1909,  xx.  757-813. 
YOTINO,  J.  K.     "  X-Ray  Diagnosis  of   Tuberculous  Hip-joint  Disease,"  Penn.  3I.J.,  Athens, 

1909,  xii.  714. 
FoRSSEL,   G.     "  X-Ray  Diagnosis  of  Tubercular  Diseases  of  Bones,"   Hygiea,  Stockholm, 

1909,  2.  f.  ix.  ;   Svetis.  Ldk.  SalM:  Forhandlung,  258-270. 
Harris,  L.  H.     "  Rontgonography  in  Disease  of  Bone,"  Australasia  M.  Congress  Tr.,  Victoria, 

1909,  iii.  175-183. 


I'LATIO     Mi.      'I'lIK    XllAV    AlTKAllASCK   UK   KAIll.V    'I'l'BKUCL'LOUS   DlsKASK   dl'   TUB    KNKK-JoINT. 

Tlu'  enils  of  llic  l>ou(/s  fonniiiK  tliu  joint  liiivc  a  I'tiiiracteristic  "smoky  "  iipiMMrniief  ;  the  outline 
of  11  thielii'iUMl  synoviiil  iiicmbniiie  can  lie  traced,  ami  the  wide  separation  ol  the  ends  of  the  bones 
indicate  the  presence  of  llniil. 


PLATE   XLI.— The  X-uay  ai'I'Eahance  op  an  Advanxed  TnBERCuuisi.s  of  thk  Knee-Joint. 

The  articular  surface  of  tlie  femur  is  eroded  and  destroyed,  the  outliiie  of  tliicliciied  synovial  membrane 
can  Ije  traced  ;  there  is  little  or  no  fluid  in  the  joint. 


X-RAY  APPEARANCES  OF  TUBERCULOUS  BONES     63 

RuCHMASX,  M.     "  The  Diagnosis  of  Bone  Lesions  b_v  means  of  the  Rontgen  Rays,"  Illinois 

Med.  Journ.,  Springfield,  1909.  xvi.  118-120. 
Freund,   L.     "  The   Treatment   of   Tuberculous   Osteoarthritis   by   Rontgen  Rays,"   Arch. 

RotUgeii  Ray,  London,  1908-9,  xiii.  89-98. 
CuSHWAY,   B.   C.     "  Differential  Diagnosis  of  Pathological  Conditions  of  the  Bones  and 

Joints  by  means  of  Rontgen  Rays,"  Quart.  Bull.  Norlhwesl  Univ.  M.  Sch.,  Chicago, 

1909-10,  xi.  105-11.5. 
Pfahler,  G.  E.     '■  Diseases  of  Bones  and  their  Differentiation  by  means  of  the  X-Raj'," 

Amer.  J.  Surg.,  New  York,  1910,  xxiv.  377-381. 
PiRlE,  G.  A.     "  Diseases  of  the  Bones  and  Joints  as  shown  by  X-Rays,"  Edin.  M.  Journ., 

1910,  N.S.  iv.  427-430. 
Skinner,  C.  H.     "  The  Rontgen  Diagnosis  of  Bone  Lesions,"  Oklahoma  M.  News  Journal, 

1910,  xviii.  143-152. 
Brooa,   a.,    and   Philbert.      "  Radiographics   de   tuberculose   diaphysaire   des   os   longs," 

Paris  med.,  1912-13,  ix.  578-582. 


64  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


PROGNOSIS  IN  BONE  AND  JOINT  TUBERCULOSIS 

If  the  prognosis  of  bone  and  joint  tuberculosis  be  considered  from  a  scien- 
tific view-point,  it  will  be  found  to  depend  upon  two  facts  :  (1)  the  general 
resistance  which  the  body  offers  to  a  tuberculous  toxaemia  and  bacillary 
dissemination  ;  (2)  the  local  resistance  to  the  spread  of  the  disease  by  the 
formation  of  a  circumscribing  fibrosis.  Viewed  from  this  standpoint,  it 
would  appear  that  the  prognosis  in  bone  disease,  in  comparison  with  many 
other  forms  of  tubercle,  is  decidedly  good.  The  disease  is  situated  in  a 
tissue  which  it  is  difficult  to  destroy  and  still  more  difficult  to  remove. 
Moreover,  it  is  a  tissue  from  which  absorption  is  small  because  of  the  peculi- 
arity of  its  blood  supply  and  the  meagreness  of  its  lymphatics,  and  for  the 
same  reason  the  dissemination  of  bacilli  is  unlikely.  Lastly,  the  disease  is 
surrounded  by  marrow  possessing  cells  of  considerable  phagocytic  powers. 
Each  of  these  points  is  favourable  to  an  arrest  of  the  disease,  both  local 
and  general,  and,  from  a  pathological  standpoint,  one  cannot  help  being 
struck  by  the  frequency  with  which  spontaneous  cure  occurs. 

Arguing  from  the  same  basis,  conditions  are  not  so  favourable  in  joint 
disease.  The  local  powers  of  resistance  are  less,  and  the  tendencies  to 
dissemination  of  toxins  and  organisms  are  greater. 

But  to  pass  from  theory  to  practical  facts  :  any  question  of  prognosis 
must  be  considered  from  two  aspects — the  prognosis  regarding  the  fife  of 
the  individual  and  the  prognosis  regarding  the  limb  or  the  local  part  affected. 

Life  Prognosis. — As  regards  the  life  prognosis,  it  may  be  considered 
in  application  both  to  bones  and  joints,  and  at  once  it  may  be  said  that  the 
prognosis  is  distinctly  good.  Children  respond  readily  to  treatment,  and 
their  powers  of  resistance  and  recuperation  are  considerable.  A  good  life 
prognosis  is  therefore  indicated  in  the  great  majority  of  cases.  Under 
certain  conditions  the  outlook  is  not  so  hopeful.  There  are  certain  features 
which,  if  present,  increase  the  risk  to  life.     These  are  : 

(1)  The  Age  of  the  Child. — If  the  disease  occurs  during  the  first  two 
years  of  life,  the  life  prognosis  is  grave. 

(2)  The  Position  of  the  Lesions. — Lesions  in  certain  bones  are  much 
graver  than  those  in  others.  The  skull  bones  and  the  spine  are  the  most 
unfavourable  situations. 

(3)  The  MuUiplicifij  of  the  Lesions. — An  extension  of  the  disease  to 
other  parts  indicates  a  want  of  general  resistance,  which  forebodes  ill  in  the 
ultimate  prognosis. 

(4)  Abscess  Formation. — This  is  serious  in  so  far  as  it  is  so  often  the 
precursor  of  the  next  danger,  namely,  septic  infection.  Yet  in  itself  it 
increases  the  gravity  of  the  disease,  because  by  its  tendency  to  burrow  it 
may  open  up  to  infection  wide  areas  of  soft  tissue. 


TREATMENT  OF  BONE  TUBERCULOSIS        65 

(5)  Mixed  Infection. — A  superadded  septic  infection  in  tuberculous 
disease  is  the  most  serious  complication  which  can  occur.  It  follows  abscess 
formation  or  imperfect  surgical  interference,  and  its  danger  lies  in  the 
apparent  impetus  which  it  gives  to  the  tuberculous  process. 

Life  is  actually  eventually  threatened  either  by  long-continued  siims 
formation  with  septic  infection  and  waxy  disease,  or  by  the  invasion  of 
vital  organs  by  the  disease.  In  this  respect  the  meninges  most  frequently 
suffer,  the  lungs  are  rarely  invaded.  Sometimes  death  occurs  from  a  miliary 
dissemination. 

Local  Progrnosis. —  The  prognosis  in  respect  of  the  local  part  differs 
considerably,  according  to  whether  a  bone  or  a  joint  is  affected.  In  bone 
disease  the  local  prognosis  is  good.  The  tissue  is  a  resistant  one,  and  there 
is  a  strong  natural  tendency  towards  cure.  Further,  as  long  as  the  disease 
is  limited  to  the  bone,  the  mobility  of  the  part  may  not  be  seriously  inter- 
fered with.  In  joints  the  conditions  are  not  so  favourable.  The  resistance 
is  certainly  less,  and  even  the  earliest  disease  interferes  with  the  functions 
of  the  part.  Sometimes  in  dealing  with  joints  a  cure  cannot  be  obtained 
unaccompanied  by  some  degree  of  ankylosis,  and  ankylosis  in  a  joint 
necessitates  a  loss  of  its  function  in  whole  or  in  part.  Therefore,  every- 
thing considered,  the  local  prognosis  in  joint  tuberculosis  is  not  so  promising 
as  it  is  in  bone  tuberculosis. 


TREATMENT  OF  BONE  TUBERCULOSIS 

The  treatment  of  bone  tuberculosis  embraces  a  wide  variety  of  jirinciples, 
treatment  local  and  general,  preventive  and  curative.  It  will  be  well  to 
discuss  the  treatment  under  several  distinct  headings  : 

1.  Preventive  treatment. 

2.  General  treatment. 

3.  Conservative  treatment. 

4.  Treatment  by  tuberculin. 

5.  Operative  treatment. 

I.  Preventive  Treatment 

It  is  an  adage  as  old  as  time  that  prevention  is  better  than  cure,  and 
surely  nowhere  can  the  application  be  more  suitable  than  in  this  bearing. 
When  one  realises  how  distressing  are  the  sequels,  no  trouble  is  surely  too 
great,  no  details  too  minute,  that  these  may  be  prevented.  First  and  fore- 
most in  the  order  of  prevention  there  comes  at  the  very  threshold  of  life 
the  question  of  milk.  Bovine  infection  most  undoubtedly  plays  its  part 
in  the  origin  of  bone  tuberculosis,  and  here  is  a  cause  crying  for  prevention. 
Sterilise  the  milk  and  the  danger  disappears.  Milk  may  be  guaranteed 
free  from  bovine  infection,  or  it  may  have  been  sterilised,  and  yet  in  spite 


66  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

of  these  precautions  a  most  obvious  preventible  error  occurs,  and  that  is  the 
contamination  of  milk  or  food  of  some  kind  with  dust  infected  with  tubercle 
bacilli.  This  applies  more  especially  to  the  conditions  under  which  the  poor 
exist.  The  third  order  in  the  scheme  of  prevention  would  be  the  non-associa- 
tion of  infants  or  children  with  consumptives.  In  a  susceptible  child  infection 
may  so  easily  occur.  A  careless  consumptive  spits  upon  the  floor,  the 
sputum  dries  and  becomes  converted  into  dust,  and  as  such  it  is  inhaled 
or  ingested  by  the  child.  It  seems  unnecessary  to  enter  a  warning  against 
the  danger  of  an  infant  kissing  a  consumptive,  and  yet  time  and  again  it  is 
a  medium  of  infection.  How  simple  are  the  principles  of  prevention,  and 
yet  how  rarely  are  they  recognised  and  observed. 

2.  General  Treatment 

(a)  Hygienic  Home  Conditions. — The  treatment  of  bone  tuberculosis 
is  such  a  long-drawn-out  process  that  only  in  the  minority  of  cases  is  the 
child  detained  in  hospital  until  cure  is  complete.  The  treatment,  therefore, 
has  often  to  be  carried  out  at  home,  where  much  may  be  done  to  improve 
the  methods  under  which  it  is  conducted.  One  has  frequently  had  necessity 
to  visit  these  cases  in  their  homes,  and  one  cannot  avoid  being  struck  by 
the  absolute  disregard  so  often  displayed  of  the  mere  elements  of  hygiene. 

One  must  preach  the  doctrine  of  fresh  air,  a  simple  subject,  but  a  most 
necessary  one.  If  a  balcony  is  available  there  the  sufferer  is  placed,  and 
there  li3  is  kept,  fijie  weather  and  foul,  night  and  day.  The  only  incon- 
venience may  be  a  passing  catarrh  ;  the  benefits  are  too  obvious  to  mention. 
If  a  balcony  is  not  available,  invention  will  meet  the  necessity.  During  the 
day  he  is  carried  to  some  open  space,  and  at  night  his  cot  rests  beneath  an 
open  window.  Attention  is  drawn  to  the  clothing.  How  often  one  sees 
the  little  suft'erer  actually  groaning  beneath  the  weight  of  garments  and  bed- 
clothes. One  is  apt  to  be  branded  as  unkind  if  one  substitutes  a  single 
garment  and  fewer  blankets,  but  one  earns  the  gratitude  of  the  small  being 
who  wears  them.  You  certainly  have  put  him  in  a  more  favourable  condi- 
tion for  his  ultimate  recovery.  According  to  the  type  of  disease  from  which 
the  child  suffers,  he  probably  is  fitted  with  a  certain  variety  of  splint,  and 
frequently  this  necessitates  a  continuous  recumbency.  If  it  does,  it  is 
advisable  that  the  patient  should  not  be  put  in  a  large  bed,  as  is  so  often 
the  case,  a  bed  shared  perhaps  by  several  members  of  the  family.  He 
should  lie  in  an  open  crib,  or  even  upon  a  home-made  trestle. 

These  facts  may  appear  trivial  in  their  simplicity,  but  they  are  most 
essential  to  proper  home  treatment.  There  are  others  too  numerous  to 
mention,  and  they  can  only  be  recognised  and  dealt  with  in  the  light  of 
actual  experience. 

(6)  Hygienic  Hospital  Conditions. — In  this  country  the  average 
tuberculous  child,  when  under  active  treatment,  has  to  be  content  with  a 
place  in  an  urban  children's  general  hospital.  No  doubt  in  every  one  of 
these  institutions  the  hygienic  conditions  are  as  perfect  as  they  can  be  made, 


TREATMENT  OF  BONE  TUBERCULOSIS        67 

yet  the  principle  of  treating  surgical  tuberculosis  in  such  for  any  length 
of  time  is  fundamentally  wrong. 

During  active  or  operative  treatment  residence  in  a  general  hospital 
is  usually  essentia],  but  during  the  long-drawn-out  period  of  after  treatment 
it  is  distinctly  inadvisable.  There  are  obvious  reasons  for  this  :  (1)  It  is 
impossible  to  keep  the  case  in  the  wards  of  a  general  hospital  until  cure  is 
complete.  (2)  No  matter  how  perfect  may  be  the  hygiene  of  an  urban 
hospital,  it  cannot  for  a  moment  compare  with  the  conditions  under  which 
tuberculous  children  may  exist  in  a  country  sanatorium.  (3)  The  presence 
of  a  child  often  with  discharging  sinuses  in  a  general  hospital  is  a  distinct 
source  of  danger  and  infection  to  those  in  contact  with  him. 

The  ideal  which  one  lays  down  is  not  a  very  hard  one.  During  the 
period  of  active  treatment  the  child  is  kept  in  a  general  children's  hospital. 
When  that  portion  of  the  treatment  which  requires  expert  interference  is 
completed  the  child  is  transferred  to  some  country  sanatorium,  where  it 
may  be  kept  indefinitely,  or  at  least  until  cure  is  completed.  This  ideal  has 
been  reached  in  several  instances.  England  has  its  Lord  Mayor  Treloar 
Home  at  Alton  and  its  hospital  at  Neuwall.  France  has  its  Berck-sur-mer 
and  many  others  ;  Germany  has  at  Rappenau  an  ideal  institution.  It 
is  a  matter  for  regret  that  as  yet  Scotland  has  not  attained  to  a  single 
institution  of  this  kind. 

In  the  building  of  these  country  sanatoria  no  elaborateness  of  construc- 
tion is  necessary.  The  actual  building  should  be  as  simple  as  possible,  the 
essential  feature  is  the  possession  of  abundant  out-door  space.  At  Berck, 
in  front  of  the  hospital,  there  is  a  wide  plage,  the  sea-front  of  Brittany, 
and  the  space  is  thronged  with  recumbent  patients,  some  on  cadres, 
some  on  the  ground,  and  some  in  voiturettes,  being  pulled  along  by 
donkeys.  One  has  got  to  see  cases  treated  under  this  regime  to  appreciate 
the  excellence  of  the  after  results. 

Surgical  sanatoria  require  no  elaborate  buildings  of  stone  and  lime. 
There  is  a  brick  and  concrete  foundation,  and  the  walls  are  built  of  wood 
and  glass.  The  wards  each  hold  an  average  of  twelve  to  twenty  children, 
and  for  preference  they  face  south  and  west.  An  elevated  situation  and 
the  most  thorough  drainage  are  necessary. 

(c)  Climatic  Conditions. — Children,  especially  those  resident  in  the 
larger  towns,  derive  the  most  extraordinary  benefit  from  change  of  air  and 
sceiu^  and  it  is  in  the  early  stages  of  tuberculosis  that  such  changes  are 
particularly  to  be  advised.  Now  change  of  air  and  scene  does  not  necessarily 
imply  a  change  of  climate.  The  latter  is  often  the  privilege  of  only  the  well- 
to-do,  and  it  is  from  the  poor  that  the  bulk  of  our  patients  are  drawn.  But 
change  one's  surroundings,  be  it  only  the  matter  of  a  measured  mile,  and 
sometimes  the  benefit  is  enormous. 

There  are  many  classifications  of  chmate.  Sufficiently  useful  for  one's 
purpose  is  that  wliicli  classifies  three  varieties — sea-coast,  inland,  and  moun- 
tainous. Each  of  these  has  got  something  to  recommend  it,  and  one  will 
endeavour  to  give  .some  ]ioints  which  will  help  towards  a  decision. 


68  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

The  sea-coast  climate  is  one  which  is  characterised  by  a  low  temperature, 
some  degree  of  moisture,  and  the  occurrence  of  winds.  In  the  treatment 
of  bone  and  joint  tuberculosis  it  forms  an  ideal  en\aronment,  and  most 
especially  for  children.  It  is  contra-indicated  in  certain  conditions — when 
the  disease  is  advanced,  when  there  is  considerable  cachexia  and  wasting, 
and  when  the  bone  or  joint  disease  is  complicated  by  infection  of  the  lungs. 

Inland  situations  are  on  the  whole  dry  and,  when  compared  to  the 
sea-coast,  of  a  higher  temperature.  They  are  more  suited  for  pulmonary 
infection  than  for  the  surgical  tuberculosis  of  children. 

Mountain  climate  has  the  characteristics  of  a  rarefied  atmosphere,  a 
slight  degree  of  humidity,  and  a  low  temperature.  Of  these  the  first  is  cer- 
tainly the  most  important.  In  1900  and  1901  some  German  physiologists 
(Zuntz,  Loewy,  Miiller,  and  Caspari)  carried  out  experiments  upon 
dogs  to  demonstrate  the  changes  produced  by  alteration  in  degree  of  rare- 
faction of  the  atmosphere.  They  showed  that  at  the  higher  altitudes  there 
are  in  the  growing  animal  an  increase  in  the  amount  of  red  blood  corpuscles 
and  haemoglobin,  a  stimulation  of  the  active  blood  -  making  function 
of  the  marrow,  and  a  relatively  greater  increase  in  growth.  Now  these 
changes  necessitate  an  improvement  in  the  blood  and  in  the  nutrition,  and 
in  the  successful  general  treatment  of  tuberculosis  no  factors  could  be  of 
more  importance.  Therefore,  if  from  no  other  than  a  physiological  reason, 
a  mountain  climate  is  ideal,  the  misfortune  is  that  its  enjoyment  is  only 
within  the  power  of  the  few.  Mountain  climate  possesses  only  one  i^ossible 
contra-indication,  and  that  is  an  excessively  irritable  state  of  the  nervous 
system. 

Dr.  A.  Rollier  of  Leysin  has  urged  the  value  of  heliotherapy  in 
surgical  tuberculosis.  The  successful  results  which  he  claims  are  largely 
ascribed  to  the  influences  of  the  ultra-violet  rays  obtained  at  high  altitudes. 

(d)  Diet. — In  surgical  tuberculosis,  more  especially  when  it  is  accom- 
panied by  a  chronic  febrile  condition,  there  is  a  continuous  loss  of  weight, 
and  it  is  mainly  to  the  diet  that  one  looks  in  counteracting  the  progressive 
wasting.  It  may  be  taken  as  a  general  rule  that  in  the  ideal  diet  fats  and 
carbohydrates;  i.e.  the  more  especially  fattening  forms  of  food,  should  be 
superabundantly  represented,  and  combined  with  them  there  ought  to  be 
a  considerable  proportion  of  albuminates. 

There  are  two  difficulties  which  meet  one  at  the  very  outset.  The  first 
of  these  is  the  occurrence  of  fever.  If  this  is  persistent  and  high,  one  may 
require  to  have  recourse  to  fluid  and  easily  absorbable  foods,  in  much  the 
same  manner  as  in  acute  febrile  diseases.  The  second  difficulty  is  the  ease 
with  which  the  digestion  is  upset,  and  then  ensues  a  want  of  appetite,  and 
even  a  positive  disgust  for  food.  This  can  usually  be  prevented  by  the 
provision  of  well-cooked,  appetising,- and  attractively  served  food.  The 
diet  of  a  child  with  tuberculous  disease  should  contain  a  liberal  allowance 
of  fatty  foods  in  the  form  of  milk,  cream,  aiid  butter.  Raw  meat  is  strongly 
recommended,  and  it  is  well  digested  by  children.  The  milk  ought  to  be 
sterilised  or  pasteurised,  and  some  expedient  may  be  followed  to  promote 


TREATMENT  OF  BONE  TUBERCULOSIS        69 

its  digestibility,  the  best  is  the  addition  to  each  glass  of  milk  of  two  table- 
spoonfuls  of  hot  water,  in  which  about  six  grains  of  bicarbonate  of  soda  and 
five  grains  of  common  salt  are  dissolved  (Burney  Yeo).  Cream  is  well 
tolerated,  and  its  value  lies  in  the  amount  of  fat  which  it  contains  ;  some- 
times it  may  be  diluted  with  hot  water,  and  this  procedure  renders  it  more 
digestible. 

The  use  of  raw  meat  has  been  largely  extolled.  It  may  be  reduced  to  a 
state  of  fine  subdivision,  it  may  be  administered  as  a  dry  powder,  or  it  may 
be  given  in  the  form  of  small,  round  pellets.  Some  children  have  an  absolute 
antipathy  to  raw  meat.  The  difficulty  may  be  overcome  by  using  meat- 
juice  or  underdone  meat.  Deboue's  forced  feeding — alimentation  forcee — 
was  once  popular  in  the  dietetics  of  tuberculosis  ;  it  is  now  rarely  used. 

Eggs  are  always  well  borne  by  children,  and  they  form  an  excellent 
diet.  The  general  rule  which  would  guide  one  would  be  a  diet  of  food, 
regular  and  plentiful,  containing  a  large  proportion  of  fat. 

(e)  Drug's. — There  are  no  specific  drugs  in  the  treatment  of  bone  tuber- 
culosis, any  which  appear  to  benefit  act  by  improving  the  powers  of  assimila- 
tion and  nutrition. 

The  preparations  of  cod-liver  oil  have  a  world-wide  reputation  ;  their 
benefit  lies  in  the  amount  of  fat  which  they  contain.  A  common  ^rror  in 
administration  is  the  giving  of  the  drug  in  far  too  large  quantities,  assimi- 
lation is  much  more  perfect  with  small  doses  than  with  large.  Malt  and 
pepsin  are  often  combined  with  cod-liver  oil ;  their  advantage  lies  in  the 
stimulation  which  they  offer  to  digestion. 

Iron  is  frequently  prescribed,  and  the  most  favourite  forms  in  which 
it  is  given  are  the  syrups  of  the  iodide  and  of  the  phosphate  of  iron.  One 
may  with  advantage  combine  these  two  preparations.  In  children  the 
prescription  of  iron  should  be  begun  with  one  of  the  simpler  preparations, 
one  of  the  scale  preparations  for  preference,  or  even  dialysed  iron,  and  the 
more  complex  preparations  are  introduced  later.  In  children  who  are  in 
any  degree  ana;mic,  the  saccharatcd  carbonate  of  iron  is  most  beneficial, 
but  it  must  be  given  in  large  doses,  thirty  grains  t.  i.  d.  Arsenic  is  recom- 
mended as  a  general  tonic.  Fowler's  solution  being  one  of  the  most  convenient 
forms. 

Much  has  been  written  lately  upon  the  effect  which  intestinal  toxaemia 
has  on  the  progress  of  tuberculosis,  and  undoubtedly  its  effect  is  a  dele- 
terious one,  therefore  one  of  the  first  princi})les  ouglit  to  be  careful  regula- 
tion of  the  bowels.  In  children  petroleum  emulsion,  ,";  i-,  given  at  bedtime 
is  an  excellent  laxative,  or  tinct.  podophyliT  \]\  ii.  t.  i.  d.  If  there  is  intestinal 
fermentation,  salol  or  sodium  sulplio-carbolate  ought  to  be  administered. 
Creasote-guaiacol  or  iodine  given  in  pepsin  is  good.  When  a  syphilitic 
taint  is  suspected  a  fraction  of  a  drop  of  Donovan's  solution  (iii].  arsenii 
et  hydrarg.  iodidi)  given  after  meals,  alternating  each  week  with  Fowler's 
solution  (liq.  arsenicalis),  will  be  found  beneficial.  Succininiide  of 
mercury  has  beei\  recommended  by  Wright.^     It  is  given  hypoderniically  in 

'  Wright,  Lancet,  1902,  vol.  i.  p.  1712. 


70  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

doses  of  ^ly  to  -^ig  of  a  grain  daily  for  fifteen  days,  a,nd  the  dose  then 
gradually  increased.  Satisfactory  results  are  obtained  by  the  use  of  tonic 
doses  of  mercuric  chloride. 


3.  Local  Conservative  Treatment 

Fixation  of  the  part. — No  treatment  has  yielded  such  good  results 
as  that  of  simple  fixation  of  the  part.  The  necessity  entailed  is  a  fixation, 
not  only  of  the  local  part,  but  also  of  the  neighbouring  joints,  a  detail  which 
one  frequently  finds  omitted. 

Principles. — The  principle  upon  which  the  treatment  is  based  is  a 
simple  one — the  nutrition  and  resistance  of  a  tissue  which  is  resting  within 
limits  are  apparently  superior  to  those  of  a  tissue  in  constant  use,  and  as 
a  result  of  the  improved  resistance  and  nutrition  the  disease  is  opposed 
and  frequently  overcome.  It  has  been  asked  why  movement,  with  the 
increased  blood  supply  which  it  entails,  should  not  be  rather  antagonistic 
to  the  spread  of  tubercle  than  otherwise.  The  answer  is  that  the  arrest  of 
tuberculous  disease  is  not  the  result  of  an  increased  blood  supply,  but  rather 
of  a  diminished  one  with  subsequent  fibrosis. 

Methods. — There  are  numerous  materials  which  at  one  time  and  another 
have  been  used  for  the  purpose  of  fixation  ;  those  in  most  common  use  will 
be  mentioned. 

(1)  Plaster  of  Paris. — Plaster  of  Paris  is  in  many  waj's  an  ideal  im- 
mobiliser.  Its  advantages  are  its  cheapness,  the  adaptability  of  its  applica- 
tion, and  the  complete  fixation  which  it  affords.  Its  disadvantages  are  few, 
possibly  two  are  most  obvious — the  weight  of  the  material  and  the  muscular 
atrophy  which  the  weight  entails.  In  the  application  of  plaster  to  a  part, 
the  operator  must  provide  himself  with  three  different  materials  :  stocking- 
ette,  plaster,  and  muslin.  Some  points  of  explanation  about  each  are 
necessary.  Stockingette  is  a  light  cotton  material,  made  in  a  tubular  form, 
and  sold  in  rolls  of  varying  sizes.  It  hes  next  the  skin,  and  by  its  elasticity 
it  naturally  accommodates  itself  very  closely  to  the  part.  It  is  a  more 
satisfactory  material  than  the  boracic  lint  which  is  so  commonly  used. 

Plaster  or  gypsum  is  a  natural  sulphate  of  lime  prepared  b}^  heating 
at  a  temperature  of  300°  to  350°  F.  to  drive  off  the  water  of  crystallisation. 
There  are  two  varieties  of  plaster — dental,  and  the  grey  or  commercial. 
For  use  with  bandages  the  dental  plaster  is  the  more  satisfactory.  Certain 
substances  are  recommended  to  be  added  to  the  plaster  to  improve  it. 
There  are  those  who  advocate  the  addition  of  dextrin,  on  the  ground  that 
it  lessens  the  tendency  which  the  plaster  has  to  crack.  It  has  the  dis- 
advantage of  considerably  delaying  the  setting.  Salt,  alum,  and  sulphate  of 
potash  are  used  because  they  increase  the  rate  at  which  the  plaster  sets. 
They  all  share  the  disadvantage  of  weakening  the  plaster.  Probably  the 
best  addition  to  make  is  Portland  cement ;  it  is  added  to  the  plaster  in  the 
amount  of  one-twentieth  part  by  volume.  It  increases  the  rate  of  setting 
and  it  materially  strengthens  the  plaster. 


I'l.A'I'K  M,I1.— TiiK  Stalks  in    ihk  siAKiM;  (iK  A   I'l.AsTiii  Casi:. 

«,  Tlie  matcriiil  wliidi  is  iiscil  in  tlic  nmliiii(,'  of  tlio  jilnster  l)unilnKc  ;  the  filgos  ni-e  carefully  fniycil. 
A,  Tlu'  teclinii'  of  loa.liii;;  the  liiimliigo  with  i)la!.ti-r  ;  one  hiinil  rolls  tlii;  biiiulnnc  wliili'  thf  olhcr  lioliis 
Ihu  ]i.irt  ulinnt  to  Iw  rolled  iindiTnunlh  n  lolk'clion  of  ilry  i>lnster.  r.  The  eorri-ct  iniuMifr  of  wrlngiiiK 
11  phistcr  li.-inilane— it  hus  \m-i\  sohUcmI  in  water.  (/,  The  wroiij;  niethoil  of  wriiiginj;  a  hanilage— l>y  this 
incthoil  the  centre  of  the  bandage  is  exlnnled.  c,  Stockingette  adjusted  to  the  liiiih.  ./',  The  idaster 
liandages  have  lieeii  apiilied  and  the  ends  ol  the  stockingette  are  tnrned  over  the  case,  i/,  The  completed 
plaster  case:  the  free  ends  of  the  stockingette  are  incorporated  in  the  case  with  n  few  turns  of  the 
jihisler  bandage. 


TREATMENT  OF  BONE  TUBERCULOSIS        71 

The  muslin  is  the  crinoline  type  of  starch  muslin,  sometimes  called 
"  tarlatan  "  or  book  muslin.  Its  mesh  ought  to  be  of  such  a  size  that 
there  are  seven  or  eight  threads  in  each  centimetre,  and  it  is  most  important 
that  it  should  have  retained  its  starch.  The  muslin  is  used  in  the  preparation 
of  plaster  bandages,  and  in  the  preparation  of  reinforcing  plaster  pads. 
Such  bandages  and  pads  may  be  made  in  one  of  two  ways  : — They  may  be 
prepared  at  the  moment  of  use.  A  solution  of  the  plaster  is  prepared, 
and  the  dry  bandage  is  soaked  and  loosely  rolled  up  in  the  plaster  solution, 
to  be  immediately  applied  to  the  part.  The  alternative  method  consists 
in  preparing  the  bandage  or  pads  beforehand  by  rubbing  the  dry  plaster 
into  the  muslin.  The  bandage  lengths  are  cut,  and  the  edges  frayed.  This 
is  done  to  prevent  cotton  threads  holding  the  bandage  up  as  it  is  being  put 
on.  The  lengths  are  loosely  rolled  into  bandages.  The  end  of  the  bandage 
is  placed  in  a  bowl  full  of  dry  plaster  and  pulled  underneath  the  plaster. 
The  bandage  is  re-rolled  from  this  end,  each  portion  being  held  under  the 
plaster  with  the  left  hand,  and  pulled  through  and  rolled  with  the  right 
hand.     The  bandages  are  rolled  loosely. 

The  technique  of  the  application  of  a  plaster  case  to  the  part  is  as 
follows  :  The  part  is  carefully  washed  with  a  solution  of  alcohol  and  ether 
in  equal  parts.  It  is  then  dusted  over  with  a  light  dusting  powder,  French 
chalk  and  talc  in  equal  parts  being  useful.  A  single  or  a  double  layer  of 
stockingette  is  now  pulled  over  the  part,  and  adjusted  so  that  it  lies  free 
of  ail  creases.  The  plaster  bandage  is  then  applied  ;  if  the  bandages  have 
been  prepared  beforehand  they  are  placed  endways  in  cold  water  and  wrung 
out.  In  wringing  out  the  bandage  an  important  detail  should  be  observed. 
It  should  not  be  wrung  out  with  a  closing  fist,  as  this  makes  it  bulge  at  one 
end,  and  it  becomes  irregular  ;  it  must  be  wrung  out  by  compression  of  each 
end  towards  the  centre.  To  secure  a  homogeneous  setting,  each  bandage 
is  wrung  out  drier  than  the  preceding.  The  casing  of  bandage  is  put  on  uni- 
formly and  carefully,  taking  the  greatest  care  to  avoid  creases.  The  case 
may  be  composed  entirely  of  bandages,  or  it  may  be  formed  partly  of  pads — 
flat  pieces  of  muslin — cut  to  fit  the  limb,  wrung  out  of  plaster,  and  applied 
anteriorly  and  posteriorly.  Tlie  plaster  should  extend  beyond  the  local 
part  so  as  to  embrace  the  joints  at  each  end.  After  it  has  become  firm, 
but  not  hard,  it  is  moulded  with  the  hands  to  the  more  prominent  outlines 
of  the  part.  While  the  ))laster  is  setting  it  will  be  noticed  that  the  casing 
becomes  distinctly  warm.  This  is  due  to  the  latent  heat  which  is  set  free. 
When  dry  there  is  little  change  in  the  bulk  of  the  splint,  the  plaster  expands, 
the  cloth  shrinks,  ami  there  is  an  actual  expansion  of  about  1  per  cent. 
The  stockingette  siiould  extend  at  each  end  for  about  one  inch  beyond  the 
plaster,  and  a  neat  finish  is  given  to  the  part  if  this  free  end  is  turned  back- 
wards over  tlie  plaster  casing. 

(2)  Cclluluid.  Celluloid  is  a  material  whicii  lias  not  been  used  sulli- 
ciently  for  bone  fixation.  It  possesses  many  advantages — perfect  fitting, 
lightness,  and  durabilit\-.  I'crliaps  its  only  disadvantage  is  the  time  wiiich 
is  required  to  conqilete  the  splint.     The  method  of  its  formation  may  be 


72  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

described  in  a  few  words.  Consider,  for  example,  the  making  of  a  splint 
to  be  applied  in  tuberculous  disease  of  the  tibia.  The  limb  from  above 
the  knee  to  the  toes  is  covered  with  warm  olive  oil,  and  upon  the  part  a  thin 
casing  of  plaster  bandages  is  applied,  and  carefully  moulded  to  the  bony 
outUnes.  When  the  casing  is  dry  it  is  cut  up  one  side,  and  carefully 
removed  from  the  limb.  From  the  mould  a  positive  cast  of  the  limb  is 
taken.  This  is  made  by  applying  a  single  plaster  bandage  around  the 
negative  to  keep  it  in  position,  blocking  up  one  open  end  by  standing  the 
negative  in  a  basin  of  sand,  and  then  filling  the  cavity  with  a  quantity  of 
plaster  of  the  consistence  of  cream.  When  the  inner  plaster  is  hard  the 
negative  is  peeled  off,  and  there  is  left  a  cast  of  the  affected  part.  The 
actual  size  of  the  cast  is  now  increased  by  covering  its  surface  with  an  addi- 
tional layer  of  plaster,  about  a  sixteenth  of  an  inch  in  thickness.  When  this 
is  perfectly  hard  the  cast  is  covered  with  a  layer  of  stockingette.  The 
stockingette  must  fit  the  cast  very  accurately,  and  to  do  so  tapes  are  tied 
around  the  various  inequalities  and  fastened  with  stitches.  The  celluloid 
solution  is  prepared  by  dissolving  sheet  celluloid  in  acetone,  and  adding  to 
the  solution  3  per  cent  of  a  solution  of  calcium  chloride  in  water,  to  render 
the  celluloid  non-inflammable  (Gauvain). 

The  fluid  celluloid  has  the  property  of  rapidly  impregnating  any  loose 
tissue  to  which  it  is  applied,  and  as  the  acetone  evaporates  a  thin,  firm 
coating  of  celluloid  is  deposited.  The  fluid  is  applied  with  a  brush  to  the 
stockingette,  covering  the  cast,  and  thoroughly  worked  in.  Two  or  three 
coats  are  thus  applied.  When  this  original  application  has  dried,  the  cast 
is  covered  with  two  pieces  of  unstiffened  book  muslin,  applied  one  in  front 
and  one  behind,  slightly  overlapping  at  the  sides.  A  further  coat  of  celluloid 
is  applied.  This  is  repeated  until  from  ten  to  fifteen  layers  of  muslin  have 
been  applied,  each  layer  being  allowed  to  dry  before  a  further  one  is  added. 
The  celluloid  is  then  cut  up  the  middle  and  removed  from  the  cast.  Its 
edges  are  trimmed,  and  they  may  be  bound  with  leather.  Hooks  for  lacing 
are  applied  along  each  side  of  the  cut  surface.  The  inside  is  lined  with  some 
soft  material,  and  the  outside  strengthened  with  narrow  steel  bands.  It  is 
a  wise  precaution  to  punch  a  number  of  holes  in  the  circumference  of  the 
splint  to  favour  evaporation  from  the  skin.  Made  in  this  way  a  celluloid 
splint  is  excellent,  and  the  results  which  it  gives  are  well  worth  the  trouble 
its  manufacture  may  have  cost. 

(3)  Wood. — W^ood  is  not  a  suitable  material.  It  is  difficult  to  fit,  and 
still  more  difficult  to  fasten  so  as  to  secure  absolute  fixation. 

(4)  Metal  Splints.— Oi  the  various  metal  splints  which  have  been  used 
aluminium  is  the  best.  It  can  easily  be  cut  into  desirable  shapes,  it  is  light, 
and  it  can  be  securely  fastened  to  the  part  by  bands  of  sticking-plaster. 
It  makes  an  excellent  splint  in  disease- of  the  wrist  and  hand  bones. 

Many  other  materials  have  been  used  :  poroplaster,  silicate  of  potas- 
sium, isinglass,  but  each  and  all  of  them  have  serious  drawbacks. 

What  is  the  length  of  time  which  a  tuberculous  bone  requires  to  be  kept 
at  rest  in  order  to  effect  a  cure  ?     It  must  be  realised  that  the  process  of 


TREATMENT  OF  BONE  TUBERCULOSIS        73 

healing  in  bone  tuberculosis  is  a  most  gradual  one.  At  least  twelve  months 
are  required  before  a  cure  is  properly  established,  and  it  is  often  wise  to  add 
an  additional  six  months.  In  certain  regions  a  still  longer  period  is  necessary. 
These  are  dealt  with  later. 


Hypersemic  Treatment 

Biers  HypercBinic  Method. — With  August  Bier  there  lies  the  credit  of 
having  introduced  a  new  method  in  the  local  treatment  of  tuberculosis. 
The  idea  was  based  upon  Rokitansky's  observation  that  patients  suffering 
from  mitral  lesions  with  pulmonary  stasis  rarely  develop  pulmonary  tubercle. 
Underlying  the  method  there  are  three  possible  processes  upon  which  the 
apparent  benefits  depend. 

Sources  of  Benefit. — (1)  The  circulation  in  the  tissues  is  altered,  the 
corpuscular  elements  become  infused  into  the  lymphatics  of  the  hyperajmic 
limb,  and  there  is  a  diffuse  oedema  throughout  the  part.  This  oedema  spreads 
from  the  periphery  to  the  centre  ;  but  when  the  stasis  has  been  kept  up  for 
some  time,  the  circulation  changes  in  direction,  and  its  course  comes  to  be 
from  the  centre  to  the  periphery.  This  circulatory  disturbance  is  beneficial 
in  two  ways  :  the  csdema  carries  into  the  very  centre  of  the  tuberculous  area 
antagonistic  products  such  as  leucocytes,  lysins,  and  opsonins  ;  the  later 
reversal  of  the  circulation  provides  for  a  rapid  removal  of  the  dead  bacteria 
and  their  products.  (2)  Artificial  hyperaemia  is  a  great  aid  to  absorption. 
This  occurs  chiefly  after  removal  of  the  medium  by  which  the  hyperaemia 
is  induced.  By  absorption  a  large  amount  of  deleterious  matter  is  rapidly 
removed.  (3)  Bier  asserts  that  hypersemia  exerts  a  solvent  action  on 
organising  tissues  and  exudation,  and  the  solution  is  preparatory  to 
absorption. 

Methofh  of  Employment. — There  are  four  methods  by  which  a  part  may 
be  made  hypencmic  : 

(a)  Active  hyperaemia. 
(6)  Passive  hyperemia. 

(c)  Hyperaemia  by  cupping  (mixed  hypcra>inia). 

(d)  Suction  hyperaemia. 

{a)  Active  Hyperaemia. — This  is  procured  by  the  local  application  of 
dry  heat.  The  part  to  be  treated  is  put  into  a  bo.x  or  chamber,  made  of 
white  wood  soaked  in  a  solution  of  silicate  of  sodium  to  prevent  charring. 
The  part  is  introduced  into  the  chamber  through  a  terminal  opening,  and 
the  opening  is  rendered  airtight  by  a  felt  cuff,  which  fits  round  the  enclosed 
member.  Into  tlie  chamber  there  opens  a  metal  tube.  Tiie  outer  end 
of  the  tube  ends  in  an  inverted  funnel,  beneath  which  a  gas-jet  plays  and 
suj)plies  heat.  Above  tlu;  inner  end  of  the  tube,  within  the  box.  there  is  a 
flat,  wooden  flange  ;  upon  it  the  hot  air  entering  tiie  chamber  st likes,  and  is 
equally  distributed.  The  amount  of  heat  is  regulated  by  raising  or  lowering 
till'  tniniiT,  and  tin'  cliiinibcr  carries  a  tliernioinctcr.     Ilyperffimia  commences 


74 


TUBERCULOSIS  OF  THP:  BONES  AND  JOINTS 


at  30°  C,  perspiration  appears  at  60°  C,  and  reaches  its  maximum  at  about 
100°  C.  114°  C.  is  the  limit  of  saturation.  Each  seance  varies  in  time  from 
thirty  minutes  to  an  hour  ;  it  may  be  repeated  twice  or  three  times  each  day. 
Active  hyperaemia  is  an  excellent  analgesic  ;  its  outfit  and  conduction  are 
expensive,  however,  and  the  ultimate  results  are  probably  not  so  suc- 
cessful as  in  passive  hypersemia. 

(6)  Passive  Hypersemia.  —  The  most  commonly  used  method  of 
inducing  passive  hyperemia  is  by  the  application  of  a  Martin's  elastic 
bandage.  The  bandage  is  of  thin  rubber  about  two  inches  wide,  and  it 
is  applied  to  the  limb  some  distance  above  the  site  of  the  disease. 
The  bandage  ought  to  be  applied  at  such  a  pressure  that  while  the  thin- 
walled,  deep,  and  superficial  veins  are  compressed,  the  thicker  arteries 
are  not  obstructed.  One  or  two  layers  of  gauze  are  applied  to  the  limb 
and  upon  these  the  bandage  is  fastened.     To  the  end  of  the  rubber  a  piece 

of  tape  is  stitched  in  order  to  facilitate 
the  tying.  The  bandage  need  not  be 
more  than  eighteen  to  twenty-four  inches 
long.  Some  practice  is  required  to  gauge 
the  degree  of  tightness  to  which  the 
bandage  should  be  applied.  The  skin 
should  be  of  a  bluish  tint,  with  dis- 
tended superficial  veins.  Prolonged 
pressure  with  the  finger  should  show 
the  presence  of  oedema.  The  pulse 
should  remain  full  and  strong,  there 
should  be  no  subjective  coldness  in  the 
part,  and  no  pain. 

Wilson  ^  has  demonstrated  a  mechani- 
cal method  of  regulating  the  pressure. 
The  pressure  bag  of  a  Riva-Rocci 
sphygmomanometer  is  applied  to  the 
limb  and  adjusted  in  position.  The  blood-pressure  is  taken,  and 
allowed  to  fall  5  or  10  mm.  below  systolic  pressure.  The  tube  from  the 
arm-pad  is  securely  clamped,  and  it  is  disconnected  from  the  apparatus. 
The  arm-pad  is  kept  in  position,  and  it  induces  a  perfect  passive  hyperaemia. 
The  bandage  should  be  applied  for  from  one  to  two  hours  each  day,  and  the 
treatment  will  probably  extend  over  nine  months.  It  is  not  advisable  to 
apply  the  bandage  for  longer  than  two  hours  a  day,  as  a  more  extended  ap- 
plication appears  to  hasten  the  formation  of  cold  abscesses.  Passive  hyper- 
ajmia  is  excellently  adapted  in  lesions  of  the  arm  up  to  the  level  of  the  elbow. 
In  the  lower  extremity  the  proper  degree  of  hyperaemia  is  difficult  to  induce. 
Ritchie  Thomson  "  has  described  a  method  which  he  has  found  useful  in 
dealing  with  the  lower  limb.  An  elastic  bandage  is  applied  above  the  knee, 
sufficiently  tightly  to  render  the  limb  bloodless.     The  bandage  is  kept  in 


4. — IJier's  ]);Ls>i\L'  liypriii'iiiiu  api'lied 
to  the  upper  extremity. 


'   Wilson,  Journ.  Amer.  Med.  Assoc,  April  4,  lfl08. 
-  G.  Ritchie  Thomson,  Transvaal  Med.  Journal,  1909. 


TEEATMENT  OF  BONE  TUBERCULOSIS        75 

position  for  five  minutes  and  then  removed.  Its  removal  is  tlie  signal  for 
a  very  active  hyperaomia  of  the  limb.  While  the  active  hypera-mia  is  in 
progress  the  elastic  bandage  is  reapplied,  just  sufficiently  tightly  to  induce 
a  passive  hypertemia. 

The  results  of  treatment  by  passive  hypersemia  are  good  in  the  upper 
limb — more  especially  in  the  terminal  portions,  carpus,  metacarpus,  and 
phalanges.  In  the  lower  extremity  the  results  are  not  so  good,  probably  on 
account  of  the  difficulty  in  inducing  the  hypersomia.  The  disadvantage  of 
the  treatment  is  the  tendency  which  it  undoubtedly  has  to  hasten  abscess 
formation ;  this,  however,  can  be  largely  avoided  by  minimising  the  length 
of  application. 

(c)  Hyperaemia  by  Means  of  Dry  Cupping  (Mixed  Hyperaemia). — 
In  localised  tuberculous  lesions  hypera3mia  is  sometimes  induced  by  a  modi- 
fication of  the  ordinary  dry  cup.  The  method  was  devised  by  Klapp, 
Professor  Bier's  assistant.  Glass  cups  of  varying  shapes  and  sizes  are  used, 
to  fit  the  different  parts  of  the  body,  and  to  the  cups  rubber  bulbs  are 
attached  in  order  to  exhaust  the  air.  A  negative  pressure  of  200  to  400 
millimetres  of  mercury  may  be  obtained.  The  area  to  be  treated  is  washed 
with  benzine,  and  then  covered  with  a  thin  layer  of  vaseline  and  lanoline. 
This  aids  the  adhesion  of  the  cup,  and  if  any  sinuses  are  present  it  diminishes 
the  tendency  to  skin  infection  and  ulceration.  The  cup  is  left  in  place  for 
five  minutes  and  removed  for  three  ;  it  is  reapplied  for  five  more  minutes 
in  a  slightly  different  place  to  avoid  skin  irritation.  The  application  should 
extend  over  forty-five  minutes,  at  first  daily,  then  every  second  or  third  day. 
Klapp  uses  these  cups  for  simple  osseous  tuberculosis,  for  infected  abscesses 
and  sinuses,  and  for  uninfected  cold  abscesses.  These  last  are  opened  by 
a  small  incision  and  "  cupped."  The  explanation  of  the  benefit  which  the 
treatment  produces  is  partly  the  result  of  a  hypersemia,  and  partly  of  an 
actual  suction  action. 

(d)  Suction  Hypersemia. — AVhen  hypcra'mia  is  to  be  induced  in  an 
entire  limb,  glass  chambers  of  varying  shapes  and  sizes  are  employed.  These 
are  provided  at  their  open  extremity  with  a  loose  rubber  cuff.  When  the  part 
has  been  placed  within  the  chamber  the  rubber  cuff  is  fastened  to  the  limb 
with  a  few  turns  of  an  Esmarcli  bandage,  to  render  the  apparatus  air-tight. 
The  air  in  the  chamber  is  partially  withdrawn  by  an  exhaust  pump,  and  a 
partial  vacuum  maintained  for  about  five  minutes;  the  air  is  then  readmitted. 
After  two  minutes  the  procedure  is  repeated,  and  so  on,  until  the  treatment 
has  extended  over  half  an  hour.  The  a})plicatioii  is  made  at  first  every  day, 
and  later  every  second  or  third  day. 

Conclimon. — In  the  upper  limbs  liyper.Tmic  treatment  of  tuberculosis 
frequently  gives  good  results,  in  the  lower  limbsthc  benefits  are  not  so  marked, 
and  in  the  neighbourhood  of  the  shoulders  and  hip  its  use  is  imi)ractical)le. 
The  results  obtained  in  (children  are  better  than  those  met  with  in  adults. 
As  a  method  of  treatment  it  must  be  combined  with  mechanical  ininioI)ilisa- 
tion.  Its  undoubtrrl  drawback  is  the  teiulcncy  to  hasten  cold  abscess 
formation. 


76  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

Counter-irritation 

In  these  days  when  radical  treatment  is  so  common,  qne  feels  one 
ought  to  apologise  for  including  counter-irritation  in  one's  scheme  of 
treatment ;  there  are,  however,  certain  cases  which  undoubtedly  benefit 
from  its  use.  The  class  of  case  which  one  finds  reacts  most  beneficially  is 
bone  disease,  uncomplicated  by  abscess  or  sinus  formation,  and  accompanied 
by  considerable  pain.  The  pain  is  the  result  of  increased  pressure  within 
the  unyielding  bone,  and  counter-irritation  improves  the  symptoms  by 
withdrawing  blood  from  the  deeper  parts  to  the  periphery,  and  thus  relieving 
the  congestion. 

Methods  of  Application. — An  excellent  method  of  employing  counter- 
irritation  is  by  the  use  of  the  cautery.  Sometimes  the  simple  actual  cautery 
is  applied  to  the  overlying  skin  at  such  a  degree  of  heat  as  to  produce  a  slight 
superficial  eschar.  More  recently  another  method  has  been  introduced. 
The  thermo-cautery,  provided  with  a  fine  platinum  point  two  millimetres 
in  thickness,  is  used;  and  v^dth  it  at  a  white  heat  a  number  of  points  of 
cauterisation  are  made  into  the  soft  tissue  overlying  the  bone.  The  bone 
itself  is  sometimes  penetrated.  As  many  as  fifty  to  sixty  points  of  cauter- 
isation may  be  made.  The  points  of  entry  of  the  cautery  are  very  small; 
and  the  whole  operation  is  conducted  with  the  most  rigorous  antiseptic 
precaution.  There  are  other  varieties  of  counter-irritants  which  are  some- 
times employed,  viz.  cantharides  blisters,  tincture  of  iodine,  etc.  None 
produces  the  improvement  which  follows  the  use  of  the  actual  cautery. 

X-Rays 

It  is  held  that  X-rays  produce  improvement  in  tuberculous  lesions. 
This  is  certainly  true  when  the  lesion  is  a  superficial  one,  the  affected 
bone  must  not  lie  at  a  greater  depth  than  4  mm.^  In  applying  the 
rays  the  surrounding  soft  parts  ought  to  be  protected,  and  it  is  advisable 
to  filter  the  rays  through  an  aluminium  plate  1  millimetre  thick. ^  No  more 
than  three  successive  applications  should  be  made  to  the  one  part.  This 
method  of  treatment  has  the  disadvantage  that  if  the  disease  lies  in  the 
neighbourhood  of  the  epiphyseal  cartilage,  the  growth  of  the  cartilage  cells 
may  be  inhibited  by  the  action  of  the  rays. 

Treatment  of  Cold  Abscesses 

Abscess  formation  is  the  most  frequent  complication  in  bone  disease. 
Its  pathology  has  already  been  fully  dealt  with,  but  to  facilitate  the 
discussion  of  the  treatment  of  the  condition,  it  will  be  well  to  recall  that 
a  cold  abscess  extends  by  an  actual  tuberculous  change  taking  place  at  its 
periphery,  and  gradually  extending  throughout  the  tissues.  It  is  not  a 
true  extension  of  pus,  but  a  gradual  extension  of  tuberculous  granulation 

'  Iselin,  Miinch.  med.  Wochenschr.,  Dec.  3  and  10,  1912. 
-  Quervain,  La  Semaine  med.,  Jan.  1,  1913,  p.  347. 


TREATMENT  OF  BONE  TUBERCULOSIS        77 

tissue,  and  the  conversion  of  the  granulation  tissue  into  pus.  When  the 
complication  arises,  its  treatment  must  be  considered,  and  there  are  a 
number  of  diiTerent  methods  which  may  be  employed.  They  may  be 
classified  as  follows  : 

(1)  Conservative  measures. 

(2)  Simple  aspiration. 

(3)  Aspiration  with  the  injection  of  medicaments. 

(4)  Simple  incision  without  drainage. 

(5)  Simple  incision  with  drainage. 

(1)  Conservative  Treatment. — There  is  no  doubt  that  an  untreated  cold 
abscess  may  be  entirely  absorbed  or  may  be  converted  into  an  innocent 
collection  of  calcareous  debris.  For  this  reason  there  exists  the  method  of 
leaving  tuberculous  abscesses  severely  alone.  This  purely  expectant  treat- 
ment must  not  be  blindly  adhered  to  in  every  instance.  There  are  certain 
conditions  which  are  suitable  for  it,  and  these  are  the  maintenance  of  good 
health  on  the  part  of  the  patient,  a  diminution  in  the  size  of  the  abscess,  and 
an  abscess  which  is  deeply  situated.  Spinal  abscesses  are  the  type  which 
most  completely  fulfil  these  desiderata.  If  treatment  is  persevered  in 
under  suitable  conditions,  the  abscess  may  become  shut  off  from  its  origin, 
and  the  locahsed  collection  of  pus  undergoes  contraction  and  absorption. 
It  may  disappear  entirely,  more  often  it  becomes  converted  into  a  small 
fibrous  nodule  with  a  caseous  or  calcareous  centre.  Tubby  ^  gives  the  follow- 
ing as  indications  for  the  conservative  treatment  : — (a)  When  the  abscess  is 
single,  and  not  tracking  in  two  or  more  directions,  (b)  When  the  recumbent 
position  is  immediately  followed  by  cessation  from  pain  and  improvement 
in  the  general  health,  (c)  The  expectant  plan  should  be  persevered  with  if 
after  a  short  trial  the  abscess  ceases  to  enlarge,  (d)  A  large  collection  of 
pus  is  no  hindrance  to  tlie  trial  of  this  method,  provided  that  the  appetite 
is  good  and  the  temperature  is  normal. 

(2)  Simple  Aspiration. — Too  often  the  tendency  is  for  a  tuberculous 
abscess  to  increase  steadily  in  size  ;  active  interference  then  becomes  neces- 
sary, and  of  the  more  active  measures,  simple  aspiration  is  the  first  which 
should  be  tried.  A  Potain's  aspirator  is  used  for  the  removal  of  the  fluid, 
and  the  most  scrupulous  asepsis  must  be  observed.  When  inserting  the 
aspirating  needle  it  is  unwise  to  enter  it  directly  into  the  most  superficial 
part  of  the  abscess ;  the  puncture  is  apt  to  be  followed  by  a  tuberculous 
sinus.  The  needle  should  ]>c  inserted  through  healthy  tissues,  being  entered 
at  some  distance  from  the  abscess.  When  the  fiuid  is  being  withdrawn, 
trouble  may  arise  by  blocking  up  of  the  cannula  by  caseous  debris.  To 
obviate  this,  a  needle  with  a  large  bore  sliouid  be  used,  the  needle  Iteing 
provided  with  a  stiletta  in  case  it  should  be  necessary  to  clear  the  lumen. 
The  fluid  is  withdrawn  under  a  negative  pressure,  and  the  ca\'ity  emptied 
as  completely  iis  possiljlc.  'I'he  needle  puncture  is  scaled  with  collodion, 
and  it  is  wise  to  diminish  the  potential  cavity  of  the  abscess  by  applying  firm 

'  Tubby,  Deformities,  including  Diseases  oj  llie  Bones  and  Joints,  vol.  ii.  p.  171. 


78 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


pressure  with  a  pad  and  bandage.  A  single  aspiration  is  almost  certainly 
followed  by  a  reaccumulation  of  fluid.  Several  successive  aspirations  may 
bring  about  a  cure. 

The  benefit  which  follows  aspiration  is  the  result  of  a  diminished  or 
negative  pressure  within  the  abscess  cavity.  The  surrounding  blood  and 
lymph  vessels  become  distended,  and  a  quantity  of  serous  fluid  is  poured 
out.  In  the  fluid  which  collects  there  are  a  number  of  bodies  antagonistic 
to  the  bacillus  and  its  products  :  precipitins,  lysins,  and  opsonins.  It  is 
from  the  action  of  these  that  a  benefit  accrues.  The  collapse  of  the  abscess 
wall  brings  the  parts  in  contact  with  the  altered  fluid. 

(3)  Aspiration  with  the  Injection  of  Medicaments. — The  idea  underlying 
this  treatment  is  that  after  removal  of  the  pus,  if  a  medicated  fluid  is  intro- 


FiG.  5. — The  technique  of  abscess  aspiration.  The  two  npper  drawings  illustrate  the  danger  of  sinus 
formation  following  tlie  direct  introduction  of  the  needle.  The  lower  drawings  illustrate  the 
beneficial  valve-like  arrangement  of  the  tissues  when  the  puncture  is  an  oblique  one. 


duced  into  the  cavity,  the  fluid  will  act  upon  the  surrounding  disease  and 
produce  a  cure.  The  technique  isvery  similar  to  that  employed  in  aspiration. 
After  removal  of  the  pus  the  cannula  is  disconnected  from  the  aspirating 
bottle.  At  the  side  of  the  cannula  there  is  an  opening  into  which  a  large 
syringe  fits  ;  by  this  lateral  opening  the  medicated  fluid  is  injected  along  the 
cannula  into  the  cavity.  A  great  variety  of  materials  have  been  used  for 
injection.  A  10  per  cent  solution  of  iodoform  in  glycerin  is  one  in  most 
common  use.  Its  advantages  are  the  simplicity  of  its  composition  and 
manufacture,  its  slow  absorption,  and  therefore  slight  toxicity,  and,  finally, 
the  property  which  it  possesses  of  uniform  dissemination  over  the  cavity. 
Kirmisson  ^  recommends  a  solution  of  iodoform  in  ether.  According  to  the 
age  of  the  patient  and  the  size  of  the  cavity,  four  standard  amounts  of  solution 
may  be  injected  :  5,  10,  15,  or  20  grammes  of  the  solution,  representing 
respectively  50  centigrammes,  1  gramme,  1  gramme  50  centigrammes,  and  2 

'  Kirmisson,  Surgery  of  Children  (trans,  by  Keogh  Murphy),  p.  384. 


TREATMENT  OF  BONE  TUBERCULOSIS        79 

grammes  of  iodoform.  After  the  abscess  is  thoroughly  evacuated  the  cavity 
is  washed  out  with  sterile  boracic  lotion,  and  the  ether  and  iodoform  injected. 
Soon  after  injection  the  ether  passes  into  a  state  of  vapour  and  distends  the 
abscess.  It  is  therefore  ad\'isable  to  keep  the  trocar,  with  closed  stop- 
cock, in  position  until  this  occurs,  and  then  to  open  the  stop-cock.  The 
ether  vapour  thus  escapes,  and  the  iodoform  is  disposed  upon  the  walls  of 
the  cavity. 

Menard  ^  recommends  the  use  of  a  thymol-camphor  injection,  prepared 
in  a  strength  of  thymol  1  part  and  camphor  2  parts.  The  amount  injected 
varies  from  5  to  40  grammes.  He  had  previousl}'  used  a  preparation  of 
naphthol  and  camphor,  but  after  two  cases  of  acute  poisoning  he  gave  up 
this  method.  It  would  appear  that  the  thymol-camphor  solution  has  a 
solvent  effect  on  the  caseous  material  within  the  abscess,  and  thus  subsequent 
evacuation  is  rendered  more  complete.  It  induces  an  irritation  of  the 
abscess  wall  and  later  a  curative  fibrosis.  Menard  recommends  that  the 
process  should  be  repeated  in  from  eight  to  twenty  days. 

Calot  ^  makes  use  of  two  solutions,  and  the  indications  for  each  differ. 
The  first  is  an  oily  solution  of  creasote  and  iodoform  (olive  oil,  70  grammes  ; 
ether,  30  grammes  ;  creasote,  5  grammes  ;  guaiacol,  1  gramme  ;  iodoform, 
10  grammes).  The  second  is  a  solution  of  naphthol  and  camphor  in  glycerin 
(naphthol-camphor,  2  grammes  ;  glycerin,  12  grammes).  The  first  solution 
is  the  one  most  generally  used  ;  the  second  is  employed  when  the  abscess 
cavity  contains  a  quantity  of  thick  caseous  matter.  Calot  considers  that 
there  is  a  further  important  indication  for  the  use  of  the  naphthol-camphor 
solution,  namely,  abscesses  which  are  not  yet  localised,  but  which  are  really 
masses  of  tuberculous  granulation  tissue,  with  some  caseation  in  the  centre. 
In  such  cases  the  solution  increases,  so  to  speak,  the  matiu'ity  of  the  abscess 
by  liquefying  the  gratuilation  tissue  of  the  abscess  wall.  Successive  aspira- 
tions, therefore,  yield  increasing  quantities  of  fluid. 

Other  materials  have  from  time  to  time  been  used.  Good  results  have 
been  obtained  by  a  10  per  cent  solution  of  zinc  chloride,  also  with  a  solution 
consisting  of — 

Tincture  of  iodine  ...  1  part. 

Iodide  of  potash     ...  1  part. 

Water  to        .  .  .  .100  parts. 

Calve  and  Gauvain  '  have  published  excellent  results  from  the  use  of  a 
solution  containing    - 

loiloforiii        ....  5  grammes. 

Kthcr 10         „ 

Guaiacol         ....  2         „ 

Creasote         ....  2         „ 

Sterile  olive  oil        .          .          .  100  ec. 

The  Explanation  of  the  Improvement  which  follows  the  Injection  of  Medica- 
menls. — It  is  supposed  that  tlic  injection  of  a  modiciited  fluid  ])ro(hice.s  an 

'    Mi'dard,  fjludc  pnitiqur,  ,^tir  Ic  mill  df  l*otl,  Paris,  I!(00,  p.  'M)\  rt  .svvy. 
-  Calot,  Orthnpi'die  indi-tj)e»»tihlr^  p.  17(>  I't  .s/v/. 
'  Calvi'  aiul  (iauvain,  I.ancrl,  Marcli  5,   1!)I(J. 


80  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

inflammatory  reaction,  with  the  exudation  of  blood  cells  and  lymph.  There 
is  an  active  diapedesis  of  the  white  cells,  and  a  fibrinous  exudate  forms 
around  the  cavity.  By  a  proliferation  of  the  fixed  connective  tissue  cells 
a  barrier  of  limiting  fibrous  tissue  is  deposited.  Thymol  has  a  specific  action 
in  actually  liquefying  caseous  material. 

Coyon  and  Fiessinger  ^  offer  a  clinical  explanation.  In  the  pus  of  an 
ordinary  abscess  they  have  shown  that  there  exists  a  proteolytic  ferment, 
analogous  to  the  tryptic  ferment  of  the  pancreas,  which  has  the  power  to 
digest  coagulated  albumens,  and  to  transform  them  into  peptones  and 
amido  acids.  This  ferment  is  liberated  by  the  destruction  of  polymorph 
leucocytes.  It  does  not  exist  in  a  simple  tuberculous  abscess,  because  there 
are  no  polymorphs.  The  injection  of  a  medicated  fluid  induces  the  accumu- 
lation of  leucocytes  and  the  production  of  the  ferment. 

(4)  Simple  Incision  without  Drainage. — By  this  is  meant  the  opening 
of  the  abscess,  the  evacuation  of  its  contents,  and  the  closing  of  the  wound 
to  secure  primary  union.  It  is  a  method  which  is  indicated  in  deeply 
situated  abscesses,  and  it  is  absolutely  contra-indicated  in  cases  in  which 
the  skin  has  become  stretched  and  undermined  from  the  accumulation  of 
subcutaneous  pus.  Primary  healing  is  essential  to  the  success  of  the 
method. 

After  opening  the  abscess,  opinion  varies  as  to  the  treatment  which 
ought  to  be  meted  out  to  the  abscess  wall.  In  Barker's  method  the  abscess 
wall  is  thoroughly  scraped  with  a  flushing  curette,  the  debris  being  washed 
away  by  a  stream  of  hot  boracic  lotion  or  saline.  There  are  some  who 
condemn  such  drastic  means,  on  the  grounds  that  the  curette  destroys  a 
beneficial  wall  of  connective  tissue  which  forms  outside  the  abscess  and 
limits  it.  They  believe  and  practise  that  it  is  sufficient  to  scrape  the  interior 
of  the  cavity  lightly  with  a  pledget  of  gauze,  afterwards  washing  away  the 
debris  with  hot  lotion.  Before  the  wound  is  closed,  an  antiseptic  application 
should  be  made  to  the  wall.  An  excellent  2)reparation  is  that  used  by 
Stiles.  It  is  a  paste  made  up  with  2  parts  of  subnitrate  of  bismuth  and  1 
part  of  iodoform,  stored  in  a  solution  of  1  in  1000  corrosive  sublimate.  The 
bismuth  is  included  to  lessen  the  absorption  and  toxicity  of  the  iodoform. 
Phelps  has  advocated  that  the  interior  of  the  abscess  should  be  touched  with 
pure  carbolic  acid,  and  the  cavity  washed  out  with  absolute  alcohol.  A  good 
application  is  the  tinctura  iodinei  (Ph.,  Edinburgh).  Its  strength  is  1  part 
of  iodine  in  16  parts  of  90  per  cent  alcohol,  and  it  dift'ers  from  the  ordinary 
tincture  in  being  without  potassium  iodide. 

The  wound  is  carefully  closed.  If  possible  deeper  structures,  muscles 
and  fasciae,  are  brought  together  over  the  cavity.  The  skin  edges  are  united 
preferably  with  "  MichaeFs  "  clips  ;  they  secure  a  broad,  healing  surface,  and 
there  is  no  penetration  of  the  skin  by  a  suture,  which  often  acts  as  a  seton. 
A  careful  and  copious  dressing  must  be  applied,  and  it  is  important  to 
exert  considerable  jiressure  over  the  abscess  cavity  by  means  of  a  specially 
arranged  pad  and  bandage. 

^  Coyon,  Fiessinger,  and  Laurens,  Journ.  des  prat..  No.  40,  Oct.  20,  1909. 


TREATMENT  OF  BONE  TUBERCULOSIS        81 

This  is  an  operation  in  which  one's  technique  cannot  be  too  careful. 
If  there  is  any  doubt  about  asepsis  it  is  wiser  to  adopt  antiseptic  methods 
throughout.  After  operation  the  abscess  cavit}-  practically  becomes  a 
hsematoma,  and  one  knows  the  persistency  of  an  infected  haematoma.  But 
even  more  important  is  the  complication  of  a  mixed  infection  in  a  hitherto 
pure  tuberculous  lesion.  The  primary  disease  spreads  rapidly,  cachexia 
and  waxy  changes  develop,  and  the  ultimate  result  is  too  frequently  fatal. 
For  these  reasons  the  operation  entails  a  very  considerable  responsibility. 

Occasionally  a  complete  removal  of  the  abscess  cavity  by  dissection 
has  been  recommended,  the  operator  cutting  through  healthy  tissues.  The 
conditions  under  which  such  an  operation  would  become  possible  are 
excessively  rare.  Too  often  size,  position,  and  migration  render  the  thing 
an  impossibility. 

(•5)  Simple  Incision  with  Drainage. — Primary  drainage  should  never  be 
attempted  in  a  tuberculous  abscess.  A  drained  wound  is  infinitely  more- 
liable  to  infection  than  one  which  is  completely  closed,  and  a  drainage  tube 
is  often  the  originator  of  an  infected  sinus.  In  a  pure  tuberculous  abscess; 
drainage  is  never  necessary  ;  it  may  become  so,  however,  when  a  mixed 
infection  makes  its  appearance. 


Treatment  of  Sinuses 

This  troublesome  complication  is  usually  the  result  of  the  secondary 
infection  of  a  tuberculous  abscess.  It  is  possible,  however,  for  a  sinus  to 
exist  which  is  purely  and  entirely  a  tuberculous  one.  The  track,  leading 
from  the  abscess  to  the  surface  of  skin  or  mucous  membrane,  is  frequently 
of  great  length,  not  because  the  abscess  lies  specially  deep,  but  because 
the  sinus  is  usually  branching  and  tortiious.  The  wall  of  the  sinus  is  lined 
by  numerous  tuberculous  follicles,  many  of  them  caseating.  Around  the 
tuberculous  granulation  tissue  there  is  a  deposit  of  fibrous  tissue,  which  keeps 
the  circumference  of  the  sinus  within  limits. 

In  itself  a  sinus  gives  rise  to  no  symptoms  beyond  its  discharge,  but 
indirectly  it  is  responsible  for  a  continuation  of  the  secondary  infection, 
the  development  of  temperature  and  cachexia,  and  eventually  for  amyloid 
degeneration  and  death.  No  pains  therefore  should  be  spared  to  prevent 
the  formation  and  to  cure  the  condition  when  it  does  occur. 

The  prevention  of  sinuses  has  already  been  dealt  with.  It  consists  in 
the  treatment  of  cold  abscesses  by  aspiration  or  incision  without  drainage, 
and  the  most  scrupulous  care  to  prevent  secondary  infection.  When  a 
sinus  has  been  established  its  cure  may  be  excessively  difficult.  It  is  rarely 
possible  to  (excise  it  on  account  of  the  extent  and  tortuosit}'  of  its  course, 
and  tlu!  dilliculty  in  securing  piiniary  union  of  the  wound.  One  therefore 
has  to  fall  back  upon  more  conservative  measures.  These  resolve  themselves 
into  two  groups  :  the  injection  of  the  sinus  with  niedicanionts.  and  I?ier's 
hypera;nuc  niellu)d. 

6 


82  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

Injection  of  Medicamenls. — Dr.  Beck  ^  of  Chicago  found  that  after  inject- 
ing sinuses  with  bismuth  paste  for  the  purpose  of  radiography,  many  of  them 
healed.  He  acted  upon  the  hint,  and  was  successful  in  obtaining  some 
cures.     At  first  Beck  used  a  preparation  containing  : 

Bismuth  subnitiate        .  .  .6  parts. 

White  wax  .  .  .  .  .1  part. 

Soft  paraffin  .  ...      1  part. 

This  mixture  he  later  discarded  because  he  found  it  difticult  to  maintain  a 
temperature  suitable  for  its  injection.     He  substituted  instead  a  mixture  of 

Bismuth  subnitrate        .  .  .1  part. 

Vasehne        .  .  .  .  .2  joarts. 

The  ingredients  are  thoroughly  mixed,  and  the  mixture  is  heated  in  a  water 
bath.  The  injection  is  made  at  a  temperature  of  about  40°  C.  A  glass 
syringe  with  a  conical  vulcanite  nozzle  is  used.  The  syringe  is  sterilised 
by  boihng,  and  afterwards  washed  out  with  absolute  alcohol  to  prevent 
any  water  gaining  access  to  the  mixture.  The  skin  around  the  sinus  is 
sterilised  with  alcohol  or  2  per  cent  iodine  in  spirit,  no  water  being  used. 
The  injection  is  made  slowly,  and  the  amount  varies  according  to  the  length 
of  the  sinus  and  the  age  of  the  child  ;  an  average  amount  is  rather  less  than 
10  cc.  As  soon  as  the  injection  is  made  the  syringe  is  withdrawn  from 
the  orifice  of  the  sinus,  and  the  opening  closed  by  quickly  applying  a  tampon 
of  sterilised  gauze  ;  this  is  fastened  in  place  by  a  rubber  bandage  or  a  piece 
of  sticking-plaster.  The  injection  is  repeated,  only  if  a  quantity  of  the 
original  injection  escapes  and  the  amount  injected  is  approximately  equal 
to  that  evacuated. 

Ridlon  and  Blanchard  ^  jjublished  in  ]  908  the  result  of  an  extensive 
trial  of  bismuth  paste  injections.  They  employed  the  bismuth  vaseline 
mixture  for  diagnostic  purposes,  and  the  bismuth,  white  wax,  and  paraffin 
mixture  for  treatment.  When  the  first  mentioned  fornmla  was  used  for 
diagnosis  it  was  evacuated  within  twenty-four  hours,  and  the  second  men- 
tioned was  then  injected  until  the  sinus  was  full.  The  details  of  injection 
were  similar  to  those  already  mentioned. 

It  is  doubtful  to  what  exactly  the  beneficial  effect  of  the  injection  is 
due.  By  some  it  is  supposed  that  the  bismuth  has  a  stimulating  effect  upon 
the  formation  of  healthy  granulation  tissue,  by  others  the  improvement  is 
said  to  be  entirel}^  due  to  the  mechanical  effect  of  the  injection. 

There  are  certain  conditions  which  contra-indicate  the  use  of  bismuth 
injection.  They  are  summarised  thus  by  Ridlon  and  Blanchard  :  *  (1)  The 
presence  of  a  sequestrum  ;  (2)  Coincident  wax\'  changes  in  the  internal 
organs  ;  (3)  When  there  are  large  distal  pus  sacs  which  become  filled  after 
repeated  injections  with  residuary  bismuth  ;  (4)  In  sinuses  of  tuberculous 
bone  disease  which  have  existed  for  less  than  two  or  three  months  ;    (5)  In 

'  E.  G.  Beck,  "  The  Surgical  Treatment  of  Tuberculous  Sinuses  and  their  Prevention," 
Transaction  of  the  Sixth  Iniernat.  Congress  on  Tuberculosis,  1908. 

^  Ridlon  and  Blanchard,  Amer.  Journ.  Orth.  Surg.,  Aug.  1908,  vol.  vi.  No.  1.  p.  13. 
3  Ibid.,  1909,  vol.  vii.  No.  1,  p.  34  et  seq. 


TREATMENT  OF  BONE  TUBERCULOSIS        83 

old  tuberculous  sinuses  with  extensive  skin  destruction  and  large  areas  of 
skin  undermined. 

The  most  urgent  danger  is  the  occurrence  of  bismuth  poisoning.  It 
takes  the  shape  of  ulcerative  stomatitis,  black  lines  at  the  gum-edge  of  the 
teeth,  diarrhcea,  cyanosis,  desquamative  nephritis,  and  loss  of  weight.  If 
the  injections  are  producing  benefit  the  secretion  from  the  sinuses  changes 
its  character,  it  becomes  seropurulent  and  serous,  and  organisms  diminish 
in  number  and  ultimately  disappear. 

In  a  paper  entitled  "  Some  Experimental  Work  on  Materials  for  Plugging 
Sinuses  and  Bone  Cavities,"  ^  Prescott  le  Breton  has  derived  benefit  from 
certain  preparations.     The  first  is  composed  of : 

Cacao  butter      .  .  .7  parts. 

White  wax         .  .  .1  part. 

Iodine  flakes. 

It  is  a  useful  preparation,  but  in  children  it  may  produce  very  considerable 
irritation. 

The  second  preparation  which  he  recommends  is : 

Borax  ...        2  parts. 

Wax  ...        1  part. 

Lanolin  .  .  .24  parts. 

This,  while  not  so  rapidly  efficacious  as  the  first  mentioned,  is  much  less 
productive  of  irritation. 

Calot '"  uses  solutions  very  similar  to  those  which  he  employs  in  the 
treatment  of  cold  abscesses,  iodoform,  creasote  oO,  and  naphthol-camphor 
glycerin.     The  composition  of  the  fir.st  is  as  follows  : 

Phenol  camplior         )    _ 
Naphthol  camphor    I   ' ' ' 
Ciiiaiacol  ..... 

Iodoform  ..... 

Lanohnc  or  Spermaceti 

The  second  is  a  weaker  mixture  : 

Phenol  camphor  |  _ 
Naphthol  cam]ihor  /  ' ' 
Guaiacol  ..... 

Iodoform  ..... 

LanoUn  or  S()erinaceti 

The  first  preparation  is  twice  as  active  as  the  second,  and  it  is  used  in  the 
smaller  tracts.  Conversely  the  second  composition  is  employed  in  the 
larger  and  more  tortuous  sinuses. 

Hypcrcvmic  Tmilmenl  of  Sinuses. — The  details  of  this  treatment  are 
best  quoted  from  Bier's  *  original  monograph  upon  the  subject : 

Recently  we  have  made  a  great  step  forward  in  the  treatment  of  tubcrcu- 
Icsis  witli  sinuses  .  .  .  by  the  resumption  by  Klapp  in  the  Bonn  polyclinic  of 

'  Amer.  Journ.  Orlh.  Surg.,  May  1010.  vol.  vii.  No.  4,  p.  404. 

-  Cali'it,  Orlliopedie  iiiiii/ipnitinblr,  .'iih  cd.,  lltll,  p.  170. 
'  Bior,  Text-book  of  Ibjperccmia,  Trannlatioii  ISIOI,  p.  2(13. 


6 

grammes. 

15 

>> 

20 
00 

" 

3 

grammes. 

8 

»» 

10 

„ 

84  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

my  treatment  for  tubercular  afEections  with  cupping  glasses,  which  I  practised 
about  ten  years  ago.  .  .  .  The  cupping  glass  is  at  first  appUed  three-quarters 
of  an  hour  daily  to  all  forms  of  open  and  fistulous  tuberculosis,  which  have  not 
been  treated  heretofore.  The  rule  laid  down  for  acute  inflammation,  that  the 
cupping  glasses  should  be  removed  for  three  minutes  after  it  has  been  applied 
for  five  minutes,  holds  good  here  also.  The  patients  are  given  daily  treatment 
until  the  indolent,  pale,  tuberculous  granulations  become  red  and  hard,  and  until 
the  immediate  vicinity  of  the  sinus  becomes  hard.  It  is  then  time  to  increase 
the  intervals  between  the  treatments,  at  first  every  second,  later  every  third, 
and  finally  every  eighth  day.  ...  In  the  vicinity  of  tuberculosis  with  sinuses 
which  have  been  treated  with  the  cupping  glass,  one  often  sees  ulcers,  which 
must  be  regarded  as  inoculated  tuberculosis.  To  avoid  this,  Klapp  suggests 
the  following  method.  After  removal  of  the  dressing,  and  previous  to  suction, 
the  vicinity  is  cleansed  with  benzine,  and  a  large  surrounding  area  is  covered 
with  fat  (lanoline,  vaseline,  aa).  After  suction  the  first  fat  is  removed  with 
benzine  and  fresh  applied. 

Wright's  Treatment. — In  treating  tuberculous  sinuses  Wright  endeavours 
to  bring  the  body  lymph,  into  contact  with  the  diseased  tissues  of  the  sinus. 
This  fluid  contains  active  bacteriotropic  powers,  and  if  it  is  allowed  to  bathe 
the  tissues  excellent  results  may  follow.  A  free  circulation  of  lymph 'is 
largely  prevented  by  fibrinous  deposits  in  the  tissues  around.  Wright 
introduces  into  the  sinus  a  solution  of  -5  per  cent  sodium  citrate  and  5 
per  cent  sodium  chloride.  A  double  purpose  is  fulfilled,  the  sodium  citrate 
prevents  coagulation  within  and  around  the  sinus,  while  the  sodium  chloride 
induces  osmosis  and  a  free  fiow  of  lymph.  The  method  of  treatment  is 
founded  upon  an  excellent  theoretical  basis,  and  in  practice  it  is  well  worth 
a  trial. 

Special  Forms  of  Treatment 

Trypsin  Treatment  of  Bone  Ttiberciilosis.  —  This  treatment  is  based 
upon  the  idea  that  the  injection  of  a  proteolytic  ferment  will  induce  the 
resolution  of  a  tuberculous  lesion.  The  method  consists  in  the  injection 
subcutaneously  of  a  sterile  60  per  cent  solution  of  trypsin  in  glycerin.  The 
dose  varies  from  1  to  2  cc,  diluted  with  one  to  ten  parts  of  physiological 
salt  solution,  and  injections  are  made  at  intervals  of  two  to  seven  days. 
The  solution  is  injected  preferably  in  the  region  of  the  tuberculous  focus. 
The  injection  is  followed  by  smarting  pain,  occasionally  a  rise  in  temperature, 
and  local  signs  of  inflammatory  reaction.  The  symptoms  disappear  in  from 
twenty-four  to  forty-eight  hours ;  the  swelling  continues  for  about  five 
days.  It  is  said  that  under  the  influence  of  the  ferment  injection  a  vigorous 
reaction  takes  place  in  the  tuberculous  focus,  and  ensuing  hypera'mia, 
cellular  infiltration,  and  proliferation  lead  to  a  transformation  of  the  sub- 
stance and  structure  of  the  pathological  tissue,  and  to  necrosis  of  the  fungoid 
masses,  without  impairing  in  any  way  the  vitality  of  the  healthy  parts. 

Biitzner  ^  quotes  four  cases  of  advanced  tuberculosis  of  the  ankle  joint 
which  yielded  admirably  to  the  treatment.     Several  of  these  were  compli- 

1  Batzner,  Practitioner,  1913,  xc.  p.  213. 


TREATMENT  OF  BONE  TUBERCULOSIS        85 

cated  by  superficial  ulceration  and  sinuses,  leading  down  to  bare  bone. 
The  cases  were  cured  respectively  in  1  year  9  months  ;  1  year  2  months  ; 
2  years  ;  and  1  year  8  months.  He  notes  that  among  the  general  effects 
of  treatment  there  is  improvement  in  general  physical  and  mental 
condition,  and  unusual  improvement  in  appetite.  He  advises  the  treatment 
in  all  surgical  tuberculosis,  especially  those  cases  complicated  by  sinuses 
and  abscesses. 

Treatment  of  Bone  Tubercle  with  Mesbe. — Hermann  and  Spangenberg 
introduced  this  substance  into  the  field  of  therapeutic  medicine.  Bietzen- 
gieger  ^  has  recounted  his  experiences  with  it  in  the  treatment  of  bone  tuber- 
culosis. Seven  cases  of  fistulous  bone  disease  were  treated.  The  mesbe  was 
applied  pure,  or  as  a  50  per  cent  ointment.  Two  of  the  cases  healed  after 
ten  weeks"  treatment,  and  apparently  the  cure  was  a  permanent  one.  In 
one  case  a  local  reaction  resulted  from  the  application,  and  there  was  a  slight 
rise  of  temperature.  In  most  of  the  cases  there  was  an  increased  discharge 
from  the  fistula.  The  remedy  is  thought  to  possess  a  specific  action  upon 
tuberculous  processes  on  account  of  its  containing  anti-tuberculous  bodies. 

Treatment  of  Bone  Tubercle  ivith  Allyl  Sulphide. — Doctor  Minchin  -  of 
Dublin  published  in  the  British  Medical  Journal  of  August  24, 1912,  the  results 
which  he  had  had  from  the  use  of  an  ointment  containing  the  active  principle 
of  garlic — ailyl  sulphide.  Its  use  has  been  tried  with  benefit  in  cases  of 
superficial  bone  tubercle,  such  as  tuberculous  dactylitis  of  the  hand  and 
foot.  There  is  remarkable  improvement  when  it  is  employed  in  cases  in 
which  the  bone  lesion  is  associated  with  tuberculous  ulceration  of  the 
overlying  skin.  The  ointment  is  applied  directly  to  the  affected  part,  and 
the  dressing  is  changed  twice  dail}'. 

4.  Tuberculin  Treatment 

Tuberculin  is  a  product  of  the  tubercle  baciUus,  containing  cither  the 
soluble  products  of  the  bacillus,  tlie  insoluble  fragments  of  the  bacillus,  or 
a  combination  of  both.  The  first  may  be  spoken  of  as  an  extract,  the 
second  and  third  come  under  the  heading  of  vaccines.  Tuberculin  is  used 
in  diagnosis,  and  its  application  in  this  relation  has  already  been  examined. 
It  is  also  used  in  treatment,  and  it  is  this  (piestion  whicli  will  now  be 
discussed. 

Varieties  of  Tuberculins. — These  may  be  divided  into  two  groups  : 
extract  tuberculins  and  vaccine  tuberculins. 

Exiracls. 

Koch's  old  tiilK'reuliii  (Syn.  T.A.). 
Bcrancck'.-!  tulxTculiri  (Syn.  T.Hk.). 
Donys'  tulji^rculiii  (Sp.  B.F.). 
Bovine  liihcn'ulin  (Syn.  P.T.O.). 


'   ^fanch.  med.  Wocheii-irlir.,  l!)i:i,  Ix.  12«. 

=  \\'.  C.  Minchin,  Treatment  oj  T utjerculosU  and  Lupu^  witli  Allyl  Sulphide,  BdiUiiTP. 
Tindiill  &  Co. 


86  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

Vaccines. 

Koch's  new  tuberculin  (Syn.  T.R.). 
Tubercle  bacilli  emulsion  (B.E.). 
Tulase  (Von  Behring). 
Bovine  tuberculin  (P.T.R.). 
Vacuum  tuberculin. 

Mode  of  Preparation. 

(1)  Extract  Tuberculin. — The  human  tubercle  bacilkis  is  grown  upon 
a  medium  of  nutrient  broth,  containing  5  per  cent  glycerin.  Into  this 
medium  a  certain  amount  of  toxic  products  from  the  bacilli  find  their  way. 
When  a  fair  amount  of  growth  has  been  obtained,  broth  medium  and  organ- 
ism are  sterilised  by  steam  for  thirty  minutes,  evaporated  to  one-tenth  of 
their  volume  by  a  temperatm-e  which  never  exceeds  70°  C,  and  finally  filtered. 
0-5  per  cent  of  phenol  is  added  to  the  resulting  fluid,  and  the  preparation 
allowed  to  stand  for  some  weeks,  when  it  is  again  filtered.  It  is  now  a  dark- 
brown  fluid,  syrup  like  in  consLstence,  and  perfectly  miscible  with  water. 
It  contains  a  large  proportion  of  glycerin  (about  50  per  cent),  10  per  cent 
of  albumoses,  the  toxic  products  of  the  tubercle  bacilli,  and  substances 
obtained  from  the  bacilli  in  the  processes  of  sterilising  and  filtering. 

(2)  Vaccine  Tuberculin. — This  is  prepared  in  two  different  ways,  as 
illustrated  by  Koch's  new  tuberculin  on  the  one  hand,  and  Koch's  bacillary 
enuilsion  on  the  other.  Koch's  new  tuberculin  is  prepared  by  grinding  up 
dried  cultures  of  virulent  bacilli  in  an  agate  mortar.  When  the  organisms 
have  been  disintegrated,  distilled  water  is  added,  and  the  mixture  centri- 
fuged.  There  results  a  clear  supernatant  fluid  and  a  white  deposit.  The 
fluid  is  decanted  ofl',  and  the  deposit,  which  is  really  composed  of  the  in- 
soluble portions  of  the  bacilli,  is  retained.  With  the  deposit  the  process  of 
dilution  and  grinding  is  repeated,  until  an  opalescent  fluid  is  obtained. 
To  that  fluid  20  per  cent  glycerin  is  added  to  prevent  decomposition. 

Koch's  bacillary  emulsion  has  a  more  simple  method  of  preparation. 
Dried  powdered  cultures  are  mixed  with  a  solution  of  equal  parts  of  glycerin 
and  water,  in  such  a  proportion  that  half  a  gramme  of  powdered  bacilli  is 
suspended  in  100  cc.  of  the  glycerin  solution.  By  prolonged  shaking  a 
fine  emulsion  is  produced. 

These  three  methods  may  be  taken  as  the  standards  upon  which  the 
manufacture  of  aU  tuberculins  is  based. 

The  Result  of  Inoculation  into  the  Body.  —  In  the  healthy 
individual  there  is  absolutely  no  result  from  the  introduction  of  even  an 
enormous  amount  of  tubercuhn  (1000  cmm.).  In  the  person  already 
infected  by  tuberculosis,  the  inoculation  of  a  minute  dose  produces  a  very 
considerable  disturbance.  This  disturbance  is  spoken  of  as  the  tuberculin 
reaction.  The  tuberculin  reaction  embraces  three  different  changes  :  (1) 
A  local  reaction,  some  degree  of  swelling  and  redness  at  the  point  of  intro- 
duction of  the  tuberculin.  (2)  A  focal  reaction,  due  to  changes  occurring  in 
the  neighbourhood  of  the  tuberculous  foci,  increased  circulation  of  blood,  and 
serous  exudation.     (3)  A  general  reaction,  due  to  the  circulation  of  toxic 


TEEATMENT  OF  BONE  TUBERCULOSIS        87 

products  derived  from  the  introduced  tuberculin,  and  characterised  by 
fever,  malaise,  body  pains,  and  headache. 

The  most  satisfactory  scientific  explanation  of  these  changes  is  supplied 
by  Wolff-Eisner's  theory.  He  supposes  that  there  is  circulating  in  the 
tissues  of  the  tuberculous  a  specific  anti-body.  On  the  introduction  of 
tuberculin  this  anti-body  attacks  the  tuberculin  molecule,  and  liberates 
from  it  certain  toxic  products.  The  circulating  toxins  produce  the  local 
reaction,  and,  if  sufficient  in  quantity,  a  general  reaction,  and  finally  the  focaJ 
reaction.  This  peculiar  property  of  the  tuberculous  tissue  to  act  upon 
tuberculin  is  spoken  of  as  "  tubercular  sensitiveness." 

In  addition  to  "  sensitiveness  "  there  exists  another  factor,  which  must 
be  understood  before  one  can  pass  to  speak  of  the  cUnical  bearings,  and  that 
is  the  question  of  "  tolerance."  When  a  small  amount  of  tuberculin  is 
injected  into  a  tuberculous  subject,  the  "  tuberculin  reaction  "  appears. 
If  a  few  weeks  later  a  second  amount  is  injected  the  process  is  faithfully 
repeated,  but  if  the  second  injection  is  made  very  soon  after  the  first  (three 
or  four  days)  its  efficiency  in  producing  a  reaction  may  be  almost  com- 
pletely annulled.  This  phenomenon  depends  upon  a  degree  of  "  tolerance  " 
induced  by  the  first  injection.  No  proper  explanation  has  been  given  of  the 
occurrence  of  tolerance,  but  it  may  depend  upon  the  formation  of  an  anti- 
body, which  either  partly  or  wholly  counteracts  the  degree  of  sensitiveness 
present. 

Methods  of  Administration  of  Tuberculin.— At  the  present  time 
two  methods  of  administration  are  practised:  (1)  The  clinical  method; 
(2)  The  scientific  method. 

(1)  The  Clinical  Method. — The  aim  of  this  method  is  to  attain  a  well- 
marked  focal  reaction  without  inducing  any  general  disturbance,  and  at 
the  same  time  to  produce  a  tolerance  to  tuberculous  poisons.  "  The  local 
hyperajmia  supplies  to  the  local  lesions  an  abundance  of  whatever  anti- 
bodies the  patient's  blood  may  possess.  The  increased  tolerance  raises  the 
well-being  of  the  patient  by  removing  to  some  extent  the  symptoms  which 
interfere  with  his  progress  "  (Riviere  '). 

The  amount  injected  varies  with  dilTerent  preparations,  but  the  ideal 
is  to  use  the  higliest  possible  dose  without  inducing  a  reaction,  and  to  inject 
gradually  increasing  amounts  at  short  intervals  in  order  to  produce  a  rising 
tolerance.  The  dosage  varies  with  the  preparation  used.  AVith  old  tubercu- 
lin, in  infants  the  initial  dose  is  usually  ,  ,',„  milligramme  ;  in  older  childi-en, 
^',,  or  .y\,  milligramme  ;  witli  new  tuberculin,  children  under  one  year 
old  may  hv.  begun  with  .,-,,',,,,,  milligramme,  older  children  with  i„,\„o 
or  ^,,,'„„  milligramme.  The  bacillary  enuilsion  is  given  to  infants  in  a  dose 
of  I  ,,,',(,0  milligramme,  older  children  getting  o  r,\,o  ^r  ^oofi  milligramme. 
Injections  ought  to  be  given  twice  weekly  in  steadily  increasing  doses,  the 
amount  of  increase  being  gauged  by  the  degree  of  reaction  induced. 

(2)  "  The  Scieydific  Method."— '\'\\\s  method  was  originally  introduced  by 
Wright,  and  it  is  the  one  most  commonly  practised  in  this  country.     Wright 

'    Kiviric,  'riilicriiilii.iin  in  tiifdiiri/  iiiiil  CliUdhiind  (Kolytiach),  p.  2i)0. 


88  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

pointed  out  that  the  tubercle  baciUus  is  one  of  a  class  of  organisms  which  is 
resisted  by  the  body  through  the  medium  of  opsonins.  These  opsonins  so 
alter  the  tubercle  bacillus  that  it  becomes  readily  destroyed  by  phagocytes. 
The  degree  of  phagocytosis  which  occurs  is  expressed  as  "  the  opsonic  index," 
and  among  healthy  people  the  quantity  of  opsonin  remains  relatively  con- 
stant between  0-8  and  1-2.  If  the  opsonic  index  in  a  tuberculous  subject 
falls  below  0-8,  there  is  very  probably  a  localised  lesion,  and  the  index  is 
lowest  at  the  tuberculous  focus.  If  the  index  fluctuates  widely,  now  high 
and  now  low,  it  points  to  a  more  extensive  disease,  lying  in  more  open 
relation  to  the  blood  stream. 

"  The  object  of  the  scientific  method  of  tuberculin  administration  is 
to  keep  the  opsonic  power  of  the  patient  for  the  longest  possible  time  at  the 
highest  possible  figure "  (Riviere). ^  To  fulfil  this  object  tuberculin  is 
administered  in  minute  doses,  with  a  sufficient  interval  between  the  injections, 
and  avoiding  any  increase  of  dosage. 

In  regard  to  dosage,  Rivike  recommends  ^xjo^y  to  ^  o  o oo  milligramme 
for  children  less  than  one  year  old.  At  five  years  ^(j-^to  o  milligramme.  For 
children  of  twelve  years  and  upwards,  xstioo  milligramme.  The  interval 
between  doses  ought  to  be  judged  very  largely  upon  the  opsonic  index,  but 
on  an  average  an  interval  of  two  weeks  is  usually  most  suitable. 

Choice  of  Method. — Now  the  question  arises  which  of  these  two  methods 
is  the  one  to  adopt  ?  Bone  and  joint  tubercle  comes  under  the  class  of 
localised  lesions.  There  is  no  great  degree  of  auto-inoculation,  and  in  the 
neighbourhood  of  the  focus  the  opsonic  index  is  low.  These  indica- 
tions are  sufficient  to  justify  one  in  adopting  the  scientific  method  of  admini- 
stration. Are  there  any  circumstances  under  which  one  would  adopt 
the  clinical  method  ?  If  the  tuberculous  lesion  is  extensive,  and  from  its 
relationship  to  the  blood  stream  a  considerable  degree  of  auto-inoculation  is 
occurring,  one  employs  the  clinical  method,  because  by  it  the  steady  increase 
of  dosage  produces  a  tolerance  sufficient  to  counteract  in  part  at  least  the 
tuberculous  auto-inoculation. 

Choice  of  Tuberculin. — In  regard  to  the  type  of  tuberculin  which 
should  be  used,  success  may  be  attained  with  any  variety  if  its  characteristics 
and  dosage  are  thoroughly  understood.  Riviere  and  Morland  ^  recommend 
that  one  of  the  vaccine  tuberculins  (endoplasm)  be  used.  Its  rate  of 
absorption  is  slower,  and  therefore  a  mild  and  prolonged  focal  reaction 
is  produced,  with  the  minimal  amount  of  general  disturbance. 

Human  and  Bovine  Tuberculins. — A  certain  proportion  of  bone  and 
joint  tuberculosis  undoubtedly  owes  its  origin  to  infection  with  the  bovine 
bacillus.  This  fact,  in  application  to  surgical  tuberculosis  generally,  has 
inaugurated  the  idea  that  these  lesions  should  be  treated  with  a  specific 
tuberculin,  human  or  bovine.  If  the.  plan  is  to  be  adopted,  there  must 
necessarily  be  either  an  examination  and  separation  of  the  organism  in  each 
individual  case,  or  an  acceptance  of  the  belief  that  surgical  tuberculosis  is  due 

1  Riviere,  op.  cil.  p.  294. 
2  Riviere  and  Morland,  Tuberculin  Treatment,  1912,  p.  197. 


TREATMENT  OF  BONE  TUBERCULOSIS        89 

to  the  bovine  bacillus,  while  pulmonary  tuberculosis  is  human  in  its  origin 
(Nathan  Raw).i  Workers  who  believe  in  the  specific  use  of  human  and 
bovine  tubercle  are  divided  into  two  schools  :  (1)  There  are  those  who 
believe  in  the  use  of  autonomous  vaccines,  and  treat  a  lesion  due  to  a  bovine 
bacillus  with  a  bovine  tuberculin,  and  vice  versa.  (2)  There  are  those,  such 
as  Spengler  -  and  Nathan  Raw,  who  use  a  human  tuberculin  for  conditions 
due  to  the  bovine  bacillus,  and  vice  versa.  Good  results  have  been  obtained 
by  representatives  of  both  schools,  and  the  probability  is  that  human  and 
bovine  bacilli  are  so  closely  related  that  the  respective  tuberculins  produce 
very  similar  results. 

There  is  one  point  which  clinically  has  been  shown  to  be  of  advantage, 
and  it  is  this  :  If  a  continuous  course  of  one  type  of  tuberculin  (human  or 
bovine)  does  not  produce  improvement,  benefit  often  results  from  suddenly 
altering  the  course  and  using  the  other  variety. 

Mixed  Infections. — Before  tuberculin  treatment  is  adopted,  a  large 
proportion  of  bone  and  joint  disease  undergoes  a  mixed  infection,  usually 
through  the  medium  of  cold  abscesses  and  sinuses.  The  most  common 
organisms  to  produce  this  secondary  infection  are  certainl}^  the  staphylo- 
cocci and  streptococci  (Petroff  ^).  When  the  clinical  method  of  tubercu- 
lin administration  is  used,  mixed  infection  is  looked  upon  as  a  distinct 
contra-indication,  but  it  is  no  precluder  of  the  scientific  method.  If  a  mixed 
infection  exists,  it  is  essential  that  the  secondary  organism  should  be  recog- 
nised and  isolated,  and  a  vaccine  prepared  from  it.  In  the  treatment 
the  secondary  vaccine  may  be  added  to  the  tuberculin,  and  the  com- 
bined injection  used  throughout.  It  is  more  satisfactory  at  first  to  treat 
the  lesions  with  a  pure  tuberculin.  Improvement  will  proceed  to  a  certain 
point,  and  the  condition  will  then  come  to  a  standstill.  This  is  the  most 
appropriate  time  at  which  to  introduce  the  secondary  vaccine,  and  its 
introduction  often  succeeds  in  curing  the  disease. 

Autogfenous  Tuberculins.— Some  authors  have  attached  considerable 
importance  to  the  use  of  an  autogenous  vaccine,  i.e.  a  tuberculin  prepared 
from  the  actual  bacillus  which  is  causing  the  disease.  Krause  *  has  carried 
out  a  number  of  investigations  upon  the  method,  and  he  is  satisfied  that 
the  results  obtained  compare  favourably  with  those  obtained  by  the  stock 
preparations.  The  method  entails  an  enormous  amount  of  labour,  and  it 
is  doubtful  whether  the  results  are  sufficiently  good  to  justify  its  use. 

Another  method  of  autogenous  treatment  is  that  in  which  a  tuberculin 
is  prepared  from  the  actual  diseased  tissue  (Eraser  and  MacGowan  ^).  A 
portion  of  the  tissue  is  ground  up  in  a  mortar  and  made  into  an  emulsion 
with  saline.  The  supernatant  fhiid  is  jiijietted  away,  and  stcrili.^ed  and 
standardised  like  a  vaccine.  The  standardisation  is  carried  out  by  the 
weight  of  the  original  tissue  used  in  the  preparation. 

'  Nathan  Haw,  Tuhcrcutose  (lierlin). 

^  Spenf^Ior.  Tuhftrk-ulinfirhftntlhimj  in  Ilnchfjfibirge  (Davos,  1004). 

'  IVtnilT,  .■Innalcs  (It  I'liiM.  1'ii.iliur,  1904,  vol.  xviii.  p.  502. 

*  Krauso,  Zeitsriir.  fiir  'I'lihertulo.w,  lilOi).  .xiv.  s.  73. 

'  Fraaer  and  Alacgowan,  Lancet,  .luiio  1912. 


90  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

The  treatment  is  begun  by  an  injection  of  10  cms.,  and  repeated  at 
intervals  of  ten  days.  Succeeding  amounts  are  increased  upon  each  occasion 
by  5  cmm.,  unless  there  is  a  severe  reaction,  in  which  case  the  amount  injected 
is  somewhat  diminished. 

Results  of  Treatment. — There  has  now  been  sufficient  time  and 
opportunity  to  judge  of  the  results  which  follow  tuberculin  treatment  in 
bone  and  joint  tuberculosis.  Opinions  upon  the  subject  can  be  gathered  by 
quotations  from  a  series  of  articles  published  during  the  past  six  years. 
They  will  be  considered  in  sequence  of  date.  In  1906  Gray  ^  published 
a  paper  upon  the  vaccine  treatment  of  surgical  tuberculosis.  Speaking  in 
relation  to  tuberculous  bones  and  joints,  he  says  : 

Here  again  the  prospect  is  a  hopeful  one,  but  ultimate  complete  success  in 
restoring  full  healthy  function  will  be  obtained,  only  by  making  a  correct  diag- 
no.sis  in  early  stages,  and  adding  T.R.  injections  to  those  well  proved  and 
approved  lines  of  treatment  usually  carried  out.  ...  A  very  different  feature 
fi'oni  the  point  of  view  of  rapid  results  is  presented  usually  by  cases  when  abscess 
formation  with  subsequent  development  of  sinuses  and  compound  infection  has 
occurred.  In  none  have  I  obtained  satisfactory  results  with  T.R.  alone,  unless 
after  operation,  and  in  the  majority,  although  great  improvement  has  occurred, 
yet  it  has  been  slow  and  subject  to  occasional  retrogression. 

In  1908  Nathan  Raw  ^  recorded  his  experiences  of  the  treatment. 

Twenty-seven  cases  of  tuberculous  joints,  mostly  of  a  chronic  or  subacute 
variety,  have  been  treated,  15  disease  of  the  knee,  8  of  the  hip,  4  of  other  joints. 
The  cases  where  the  best  results  were  obtained  were  those  in  which  there  was 
some  suppuration  or  sinus  directly  leading  down  to  tuberculous  disease.  ...  In 
the  great  majority  of  cases  the  suppuration  first  ceased,  and  then  the  sinus  closed. 
...  In  cases  of  pulpy  disease  of  the  joints  there  was  in  many  instances  marked 
diminution  in  the  size  of  the  joints,  with  absence  of  inflammation  and  more 
movement.  ...  I  have  not  yet  seen  any  case  where  fixed  and  aukylosed  joints 
have  been  benefited. 

The  next  in  the  series  are  the  results  of  Maynard  Smith,*  published  in 
1909.  Information  was  gathered  from  34  cases.  In  16  cases  treatment 
by  splinting,  rest,  and  operation  was  first  tried,  and  because  there  was  no 
improvement  tuberculin  treatment  was  introduced.  In  10  out  of  tlie  16 
cases  complete  cure  resulted,  with  absolute  restoration  of  jomt  function. 
Three  cases  were  treated  with  tuberculin  from  the  beginning,  two  were 
completely  cured.  Of  the  remaining  15  cases,  6  were  cured,  5  improved, 
while  2  showed  no  improvement. 

Painter  *  published  in  1910  a  long  paper  upon  "  Vaccine  Therapy  in  the 
Management  of  Arthritis."     His  conclusion  is  as  follows  : 

As  regards  tuberculous  joint  infection,  there  does  not  seem  as  yet  to  be  any 

^  H.  M.  Gray,  "  Vaccine  Treatment  in  Surgery,"  Lancet,  April  21,  1906. 
^  Nathan  Raw,  "  Tuberculosis  treated  by  different  Kinds  of  Tuberculin,"  Lancet,  Feb. 
13,  1908,  p.  482. 

»  Smith,  "  The  Inoc.  Treatment  o£  T.B.  Arthritis,"  B.M.J.,  Oct.  9,  1909,  p.  1040. 
■•  Painter,  Trans.  Amer.  Cong.  PJiys.  arid  Sura.,  1910,  vol.  viii.  p.  344,  et  seq. 


TREATMENT  OF  BONE  TUBERCULOSIS        91 

■well-established  ground  for  a  belief  that  vaccination  after  infection  could  play 
a  curative  role.     Practically  there  is  very  little  evidence  that  it  ever  does. 

Finally,  one  records  the  most  recent  opinion  ;  it  is  that  of  Forster.^ 
He  reports  the  tuberculin  treatment  in  21  cases  of  tuberculous  bones  and 
joints  in  children.  Of  the  21  cases  recorded,  3  were  not  benefited,  while 
marked  improvement  was  shown  in  all  the  others.  The  routine  treatment 
of  surgical  tuberculosis — rest,  fresh  air,  and  food — was  used  Ln  all  the  cases. 

Conclusions. — In  judging  of  the  ultimate  value  of  the  treatment,  it 
is  difficult  to  appreciate  the  exact  amount  of  benefit  which  is  due  to  the 
tuberculin.  Much  of  the  improvement  which  one  sees  is  the  result  of  the 
rest  and  the  other  conservative  measures  adopted,  and  of  course  one  never 
has  an  opportunity  of  judging  a  case  treated  purely  by  injection.  In  early 
cases  it  may  be  unnecessary  to  employ  tuberculin,  but  on  the  other  hand  it 
may  advantageously  be  combined  with  the  usual  conservative  measures. 
In  later  cases,  when  suppuration  and  sinus  formation  have  occurred,  tuber- 
culin has  perhaps  its  widest  sphere  of  usefulness,  especially  when  there  is 
combined  with  it  a  vaccine  of  the  organism  or  organisms  producing  the 
secondary  infection. 

Marmopek's  Serum. — Marmorek's  -  serum  is  prepared  by  injecting 
horses  for  seven  or  eight  months  with  filtered  young  cultures  of  tubercle 
bacilli,  grown  on  a  fluid  medium  consisting  of  calf  serum  and  glycerinated 
liver  bouillon.  The  calf  serimi  is  rendered  leucotoxic  by  previously  treating 
the  calf  with  injections  of  guinea-pig's  blood.  The  effect  of  the  leucotoxic 
property  is  that  bacilli  growTi  in  the  blood  set  free  tuberculo-toxin.  By 
injecting  the  filtered  cultures  into  horses,  it  is  claimed  that  a  special  anti- 
toxin is  obtained,  which  is  able  to  confer  immunity  of  a  passive  character 
on  animals.  The  serum  is  given  by  subcutaneous  injection,  or  by  the  rectum 
after  a  cleansing  enema. 

Hoft'a  *  has  used  the  .scrum  in  a  number  of  cases  of  bone  and  joint  tuber- 
culosis. He  concludes  that  it  exerts  a  specific  reaction,  and  he  believes  that 
it  is  likely  to  become  a  valuable  means  of  combating  surgical  tuberculosis. 

Van  lluellen  '  n'])()rts  Sonnenburgs  ox])erionces  with  37  cases. 
The  results  on  the  whole  were  good.  Joint  disease  showed  the  least  im- 
provement. 

Results  have  been  published  by  Schenker,''  Hohmeier,"  and  Glaessner," 
and  the  general  conclusion  arrived  at  is  that  the  use  of  the  serum  produces 
distinct  iinprovi'nicnt  in  the  tuberculous  lesion. 

Spengler's  I.K.  Serum.-  This  is  a  preparation  of  tuberculosis-immune 
liloiKJ  made  by  extracting  the  red  blood  cells  of  immunised  sheep  and  rabbits. 

'  C.  Forater,  "  Tuberculin  Treatment  of  Surgieal  Tuberculosis  in  Children,"  Beilr.  zu 

Klin,  der  Tubcrkulose,  Wiir/.biirn,  1913. 

^  Marniorok,   Von  Siitlim-  Ilifijeia,  1900. 

»  llomi.,  IJerlin.  klin.   \i<,rheu«chr..  190(i.  No.  44. 

'  \iin  lluclion,  Cenlmlhl.  far  fhlr.,  1907.  No.  3. 

'  SilionUcr,  Milnili.  iiirtl.  Wocliensrhr.,  1907,  No.  3. 

"  Holimcicr,  Miimli.  iiiiil.  \Viielieii«rhr.,  April  14,  190S. 

'  Glaessner,  Uculschc  tiud.  W'oclieiiDchr.,  1909,  No.  17,  p.  763. 


92  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

It  is  described  as  cLemically  pure,  free  from  albumen  and  hsemoglobin,  and 
containing  one  million  lytic  and  antitoxic  units  in  each  cubic  centimetre. 
Dilutions  are  prepared,  varying  in  strength  from  1  in  10  to  1  in  10,000,000, 
of  the  original  I.K.,  and  in  all  there  are  seven  of  these  dilutions.  In  children 
a  suitable  initial  dose  is  0-1  cc.  of  the  fifth  dilution  i.e.  1  in  100,000.  The 
injections  are  repeated  at  intervals  of  a  week,  the  amount  of  each  injection 
being  increased  by  0-1  cc.  Experiences  of  the  treatment  have  been  pub- 
lished by  Porter  and  Quinn,^  and  by  H.  0.  Eversole.^  The  results  obtained 
have  been  satisfactory. 

Mehnarto's  Serum. — Dr.  Mehnarto  of  Heidelberg  has  introduced  a 
serum  to  which  he  has  given  the  name  of  contra-toxine.  The  idea 
underlying  contra-toxine  is  to  use  the  serum  of  a  warm-blooded  animal 
naturally  immune  to  tuberculosis,  and  to  sensitise  or  correct  the  serum 
by  the  addition  of  other  sera,  which  will  prevent  the  hsemolytic  and 
anaphylactic  tendencies  of  the  original  serum  without  impairing  its 
bactericidal  qualities. 

With  regard  to  dosage  a  child  is  given,  2  cc.  At  the  end  of  a  week  a 
second  injection  of  4  cc.  is  given,  and  the  injections  are  repeated  twice 
a  week,  until  the  physical  condition  shows  a  complete  cessation  of 
activity.  The  treatment  is  still  sub  judice.  So  far  the  results  obtained 
have  been  promising. 

5.  Operative  Treatment  of  Bone  Tuberculosis 

At  this  stage  only  the  leading  points  can  be  dealt  with,  full  details  are 
given  in  the  sections  on  indi\'idual  bones  and  joints.  The  question  under 
consideration  entaUs  two  problems  :  What  are  the  indications  for  operative 
treatment  ?  and,  when  operative  measures  have  been  decided  upon,  In  what 
do  they  consist  ? 

Indications  for  Operative  Treatment. — Every  one  is  agreed  that 
a  full  and  complete  trial  ought  to  be  given  to  conservative  means  before 
there  is  any  question  of  operation.  The  majority  are  convinced,  on  the 
other  hand,  that  it  is  unwise  to  delay  operative  measures  until  there  is  much 
bone  destruction,  secondary  infection,  and  sinus  formation.  There  exists, 
therefore,  between  what  one  may  term  certainties,  a  wide  area  of  dubiety. 
It  is  here  that  the  difficulty  arises,  and  it  is  well  that  one  should  consider  the 
points  which  help  one  in  deciding  the  line  of  treatment  to  adopt. 

Age. — It  is  important  to  keep  in  view  the  fact  that  one  is  dealing  entirely 
with  children,  and  one's  remarks  are  necessarily  influenced  by  this  fact. 
As  a  class,  children  offer  considerable  resistance  to  the  development  of 
tubercle,  and  in  application  to  bone  tuberculosis  this  is  especially  true. 
When  one  comes  to  examine  the  age-period  more  individually,  one  finds 
that  this  resistance  is  at  its  lowest  during  the  first  year  of  life,  thereafter  it 
increases  steadily  dming  the  age-period  of  childhood.     The  practical  bearing 

'  J.  L.  Porter  and  L.  C.  Quiiin,  Chicago  Med.  Re,c.,  1912,  xxxiv.  84-91: 
2  H.  0.  Eversolc,  Amer.  Journ.  Orih.  i^urtj.,  1912-13,  x.  234-242. 


TREATMENT  OF  BONE  TUBERCULOSIS        93 

of  these  points  upon  the  question  at  issue  is  as  follows  :  If  operation  pro- 
cedure is  recommended,  it  must  of  necessity  be  complete  and  thorough. 
In  a  child  of  less  than  two  years  old  this  may  necessitate  a  most 
extensive  operation,  and  one  associated  with  considerable  shock.  Further, 
if  the  disease  be  not  thoroughly  removed,  the  small  resistance  of  infancy 
greatly  increases  the  risk  of  recurrence,  a  risk  which  may  be  counterbalanced 
in  older  children.  One  may  put  it  in  this  way.  Looking  at  the  matter 
purely  from  the  point  of  view  of  age,  one  is  disinclined  to  urge  operation 
during  the  first  two  years  of  life.  At  a  later  period,  in  a  case  perhaps  exactly 
sinrilar  from  a  clinical  aspect,  one  would  recommend  operative  interference. 

Family  History. — This  is  a  point  which  ought  to  be  carefully  considered. 
The  question  of  heredity  has  been  already  discussed,  and  while  one  may 
neglect  such  a  possibility  as  a  true  congenital  tuberculosis,  there  is  un- 
doubtedly an  inherited  predisposition  to  tuberculosis.  If  tuberculous 
disease  appears  in  a  child  whose  family  history  is  bad,  and  the  disease  is  at 
all  amenable  to  operative  treatment,  then  undoubtedly  such  treatment 
ought  to  be  adopted.  If  the  disease  is  treated  early,  complete  removal 
may  spell  a  complete  cure.  If  there  is  delay,  one  finds  scanty  tendency 
towards  natural  cure,  but  rather  a  metastasis  and  progression  of  the  disease. 
Therefore,  other  things  being  equal,  a  tuberculous  family  history  influences 
one  in  urging  operative  treatment  where  otherwise  there  might  be  doubt. 

Social  Position. — The  conservative  treatment  of  tubercle  may  necessi- 
tate a  prolonged  and  exacting  recumbency.  In  the  children  of  the  well-to-do 
such  a  course  is  perfectly  feasible,  but  among  the  poorer  classes  it  may 
constitute  an  impossibility.  The  time  will  come,  and  one  hopes  it  is  not 
very  far  distant,  when  this  statement  will  be  in  error,  at  present  one  must 
face  the  fact  of  its  veracity.  As  operative  measures  therefore  shorten  the 
duration  of  treatment,  there  are  cases  in  which,  purely  from  the  consideration 
of  the  wretched  social  conditions,  one  recommends  an  operation.  The 
child  is  admitted  to  hospital,  the  disease  is  entirely  removed,  a  period  is 
spent  in  a  convalescent  home,  and  the  treatment  is  terminated.  There  may 
have  been  a  sacrifice  from  the  ajsthctic  point  of  view,  but  that  is  much  more 
than  counterbalanced  by  the  brevity  of  treatment. 

The  Position  of  the  Lesion  and  the  Bone  Affected. — There  are  certain  bones 
which,  from  their  anatomical  position  do  not  permit  of  operative  measures, 
these  are  comparatively  few.  Upon  the  other  hand  there  are  bones  which 
from  the  point  of  view  of  their  locality  indicate  operation.  For  example, 
in  dealing  with  fingers  and  toes,  one  would  advise  operation  in  the  toes 
but  conservative  measures  for  the  hands.  Where  a  limb  is  supported  by 
two  bones,  and  one  is  diseased,  operation  may  be  recommended,  whereas 
had  there  been  only  a  single  bone,  such  a  procedure  would  have  been  con- 
sidered contra-indicated.  Hut  even  more  important  than  the  gross  position 
is  the  e.xact  localisation  of  the  focus  in  the  affected  bone.  If  the  disease  lies 
in  the  immediate  neiglibourhood  of  a  joint,  and  has  not  yet  invaded  that 
joint,  there  is  a  very  distinct  advantage  in  removing  the  infected  tissue 
before  the  joint  becomes  involved. 


94  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

The  Multiplicity  of  the  Lesion. — It  is  difficult  to  appreciate  whether  this 
should  be  taken  as  an  indication  for  operation  or  the  reverse.  It  is  probably 
wisest  to  consider  the  matter  in  the  light  of  the  case  history.  If  the  affected 
bone  has  been  the  original  source  of  the  infection,  and  if  from  it  by  dissemina- 
tion there  have  appeared  a  number  of  minor  secondary  foci,  it  is  wise  to 
attempt  the  removal  of  the  original  disease.  It  is  possible  that  the  secondary 
foci  may  themselves  resolve  spontaneously  or  under  suitable  treatment. 
But  if,  on  the  other  hand,  the  bone  focus  is  itself  secondary  to  an  earlier 
infection,  or  if  the  dissemination  which  it  has  induced  is  well  developed  and 
advanced,  operation  is  certainly  inadvisable. 

Tlie  Clinical  Features. — The  first  consideration  is  the  opportunity  which 
has  already  been  given  for  the  disease  becoming  cured  by  non-operative 
measures.  If  at  the  end  of  six  to  nine  months  of  conservative  treatment  the 
disease  is  not  improving,  but  is  becoming  rather  more  extensive  and  estab- 
lished, it  is  well  to  interfere,  and  few  mistakes  are  commoner  than  that  of 
delaying  too  long.  The  second  clinical  feature  to  which  importance  must  be 
attached  is  the  question  of  cold  abscess  formation.  It  does  not  of  necessity 
indicate  operation,  but  in  a  doubtful  case  its  occurrence  influences  one  in  that 
direction.  Lastly,  there  are  the  signs  which  are  so  often  terminal,  such 
as  cachexia  and  waxy  disease.  They  are  the  signals  that  nature's 
resistance  is  at  an  end,  and  if  life  is  to  be  saved,  drastic  measures  require 
to  be  employed. 

X-Ray  Appearances. — Apart  from  what  has  been  said  in  regard  to  the 
situation  of  the  disease,  and  it  of  course  is  best  demonstrated  by  radiography, 
there  is  the  important  point  of  sequestrum  formation.  A  sequestrum,  if 
it  is  of  any  size,  is  not  readily  absorbed,  it  leads  sooner  or  later  to  cold  abscess 
and  sinus  formation.  One  may  take  it  that  sequestrum  formation  is  a 
definite  indication  for  operation.  These  are  the  points  which  influence  the 
observer,  but  they  have  special  bearings  in  individual  situations,  and  under 
the  head  of  these  situations  they  will  be  discussed. 

Varieties  of  Operative  Measures.  Preliminaries  to  Operation — 
Opsonic  Index. — There  are  several  points  which  require  special  mention. 
The  first  is  the  question  of  opsonic  index,  and  its  application  in  relation 
to  positive  and  negative  phases.  By  estimating  the  opsonic  index  there 
may  be  chosen,  as  far  as  science  can  tell,  the  most  suitable  period  at  which 
to  conduct  the  operative  measure,  the  most  advantageous  time  being  after 
the  commencement  of  the  positive  phase. 

Local  Preparation. — The  second  preUminary  deals  with  the  local  pre- 
paration of  the  part.  It  is  essential  that  this  should  be  extensive,  even  more 
thorough  than  might  at  first  appear  necessary  ;  it  is  often  impossible  to 
foretell  to  what  extent  the  operation  may  extend.  Further,  in  the  prepara- 
tion it  is  unwise  to  use  strong  antiseptics.  The  skin  overlying  a  cold  abscess 
is  usually  of  very  doubtful  vitality,  and  the  application  of  1  in  20  carbolic, 
for  example,  may  produce  sloughing.  Three  per  cent  iodine  in  rectified 
spirit  is  the  most  suitable  application  to  use. 

Tourniquet. — Lastly,    there    is   the    question    of    using   an    Esmarch's 


TREATMENT  OF  BONE  TUBERCULOSIS        95 

bandage  as  a  prelude  to  operation.  Its  supporters  have  argued  that  its  use 
prevents  a  troublesome  oozing.  This  may  certainly  be  true,  but  there  is 
the  disadvantage,  that  if  the  oozing  does  not  occur  at  the  time,  it  makes  its 
appearance  later,  and  often  necessitates  a  most  undesirable  drainage.  It  is 
well  to  avoid  the  application  of  the  elastic  bandage. 

Types  of  Operation 

(1)  Gouging-  and  Scraping-. — This  consists  in  freely  exposing  the 
affected  bone,  and  removing  from  it  with  gouge  and  sharp  spoon  the 
diseased  focus.  In  exposing  the  bone  it  is  usual  to  choose  a  suit- 
able intermuscular  plane  in  order  to  avoid  damaging  the  tissues.  Of 
necessity  the  incisions  .will  vary  in  different  localities.  The  periosteum  is 
separated  to  expose  healthy  bone,  above  and  below  the  disease.  The 
medulla  is  opened  with  gouge  and  hammer,  or  with  a  small  trephine.  With 
a  sharp  spoon  the  diseased  material  is  thoroughly  curetted  from  the  interior 
of  the  bone,  until  there  is  a  cavity  lined  by  healthy  cancellous  tissue. 

As  it  is  almost  impossible  to  avoid  infecting  the  wall  with  tuberculous 
material,  it  is  well  to  disinfect  the  walls  with  some  preparation  of  iodoform  or 
pure  carbolic.  The  cavity  that  is  left  may  be  treated  in  various  ways.  The 
following  are  the  most  important. 

(a)  It  may  be  stufEed  with  iodoform  gauze,  and  the  space  encouraged 
to  close  partly  by  the  formation  of  fibrous  tissue,  and  partly  by  the  develop- 
ment of  new  bone,  the  packing  being  continued  until  there  is  complete 
obliteration. 

(b)  Moselig  MoorhoJ's  Plug} — All  blood  clot  is  removed  from  the  cavity 
by  packing  with  gauze  wrung  out  of  hydrogen  peroxide.  The  walls  of  the 
cavity  are  thoroughly  dried  with  a  hot-air  douche,  of  which  the  dentist's 
pattern,  upon  a  larger  scale,  is  one  of  the  best.  The  material  used  to  fill  the 
cavity  is  next  prepared.  It  is  composed  of  iodoform  60  parts,  spermaceti 
40  parts,  oil  of  sesame  40  parts.  The  total  ingredients  are  heated  slowly 
to  a  temperature  of  100°  C,  and  after  being  thoroughly  mixed,  are  allowed 
to  cool.  Immediately  before  use  the  mixture  is  heated  in  a  water-bath  to 
60°  C.  to  render  it  fluid,  and  then  poured  carefully  into  the  dry  bone  cavity. 
In  filling  the  cavity  it  is  exceedingly  important  to  prevent  the  entry  of  any 
air  bubbles,  and  further  to  fill  the  space  as  completely  as  possible.  When 
the  mass  solidifies  the  soft  parts  are  replaced. 

{(■)  Nciibcr's  lodojorm  Starch.  This  is  used  in  the  same  fashion  as 
Mosetig-Moorhof's  wax,  and  Neuber  considers  the  method  most  suitable 
in  the  removal  of  superficial  tuberculous  foci.  Ten  grammes  of  wheat-starch 
arc  mixed  witli  the  smallest  ])ossible  quantity  of  water,  and  to  the  mixture 
one  adds  2(J0  grammes  of  boiling  "2  i)er  cent  watery  carbolic  solution.  After 
partial  cooling,  10  grammes  of  ])owdcred  iodoform  are  added.  The  prepara- 
tion should  !)(!  kejit  in  the  dark,  and  it  is  used  in  exactly  the  same 
fashion  as  Mosetig-Moorhof's  wax. 

'  Mosotig-lloorliof,  Xeitschr.  fiir  Cliiniry.,  Aiiril  18,  190H. 


96  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

(d)  Schede's  Aseptic  Blood  Clot. — If  the  bone  cavity  is  not  packed  or 
filled  in  any  way,  sufficient  bleeding  occurs  to  fill  it  with  a  quantity  of  blood 
clot.  The  periosteum  and  soft  parts  are  sutured  over  the  cavity,  the  skin 
wound  is  closed,  except  to  permit  of  drainage  by  a  single  strand  of  catgut 
or  rubber  tissue.  The  part  is  abundantly  dressed  and  put  up  in  a  vertical 
position.  This  prevents  any  inconvenient  bleeding,  and  the  excess  of  blood 
is  carried  by  the  drain  into  the  dressings.  The  organising  blood  clot  acts 
as  a  scaffolding,  upon  which  fresh  tissue  quickly  develops,  and  even  a  cavity 
of  considerable  size  will  close  in  about  six  weeks.  It  is  absolutely  essential 
to  observe  the  most  rigid  asepsis  ;  infection  is  disastrous  to  the  success  of 
the  method. 

(e)  Senn's  Decalcified  Bone  Chips. — The  chips  are  prepared  from  the 
compact  fresh  bone  of  the  ox.  The  bone  is  cut  into  long  narrow  strips, 
and  decalcified  by  immersion  in  a  10  per  cent  watery  solution  of  hydro- 
chloric acid.  The  fluid  is  changed  frequently,  and  the  decalcification  is 
complete  in  about  two  weeks.  To  remove  all  traces  of  the  acid,  the  bone  is 
washed  in  running  water  for  twenty-four  hours,  soaked  in  I  in  1000  mercuric 
chloride  for  forty-eight  hours,  and  stored  in  a  saturated  solution  of  iodoform 
in  ether.  Before  use  the  chips  are  soaked  in  alcohol  to  remove  the  iodoform 
and  ether  and  then  carefully  dried.  The  cavity  is  filled  completely  with 
the  bone  chips,  and  the  interspaces  are  occupied  by  blood  clot.  It  is  claimed 
that  the  bones  strengthen  the  frame-work  of  blood  clot  into  which  the 
healthy  granulation  tissue  penetrates.  Instead  of  decalcified  bone,  chips 
of  fresh  bone  have  been  used. 

(/)  Murphy's  Glycero-gelatin-Jormalin  Plug. — 100  cc.  of  white  gelatin 
are  boiled  in  150  cc.  of  glycerin  and  500  cc.  of  water.  To  the  mixture  1 
to  2  per  cent  of  commercial  formalin  is  added. 

{g)  Beck's  Paste  (page  82).  This  may  be  used  in  a  manner  similar  to 
iodoform  wax  or  Neuber's  starch. 

When  the  cavity  has  been  treated  by  one  of  the  above  methods,  the 
soft  parts  are  brought  together  over  it.  It  is  usually  impossible  to  obtain 
a  periosteal  covering,  but  muscles  and  fasciae  are  available. 

After-treatment. — There  are  certain  important  features  in  the  after- 
treatment  which  require  to  be  recognised.  It  is  important  to  maintain 
rigid  asepsis,  and  for  this  reason  it  is  well  to  avoid  frequent  and  unnecessary 
dressing.  While  the  wound  is  healing  the  part  must  be  immobilised  upon 
some  form  of  light  splint,  readily  adaptable  to  the  limb.  Aluminium 
answers  the  purpose  in  the  majority  of  instances.  When  the  wound  is 
healed  the  part  is  encased  in  a  light  splint  of  plaster  of  Paris,  and  this  is 
kept  in  position  for  from  three  months  to  six.  If  the  wound  is  not  com- 
pletely healed  a  plaster  case  may  still  be  ajjplied  if  a  window  is  cut  out  to 
permit  of  dressing.  The  prolonged  fixation  in  after-treatment  is  very 
essential,  even  though  it  would  appear  that  all  trace  of  the  disease  had  been 
removed. 

(2)  The  Resection  Operation.~Mr.  Stiles  ^  first  brought  this  procedure 

1  stiles,  Burgliard's  Operative  Surgery,  vol.  ii.  p.  7. 


TREATMENT  OF  BONE  TUBERCULOSIS        97 

into  active  use,  and  for  many  years  he  has  used  it  to  the  exclusion  of  other 
methods.     By  the  aid  of  skiagraphy  the  disease  is  locaUsed  within  the  bone, 
and  conditions  are  most  favourable  when  a  limited  area  is  involved.     Not 
that  diffuseness  is  a  contra-indication,  for  the  whole  diaphysis  may  be 
removed.     It  is  well  that  the  disease  should  lie  within  the  hmits  of  the  bone 
and  not  have  involved  the  surrounding  soft  tissues.     The  bone  is  exposed 
by  a  suitable  incision,  and  the  periosteum  separated  from  it  well  above  and 
below  the  disease.     The  bone  is  divided  at  one  side  of  and  at  some  distance 
from  the  disease.     The  division  is  best  carried  out  with  a  Gigli  saw,  or  in 
small  bones  with  a  bone  forceps.     When  the  bone  has  been  divided,  a  strong 
sharp  hook  is  introduced  into  the  medullary  ca\aty,  and  by  the  leverage  of 
the  hook  the  diseased  bone  is  strongly  pulled  upwards,  and  fiuther  separated 
from  its  periosteal  bed.    The  further  limit  of  the  disease  having  been  reached, 
the  bone  is  again  divided,  and  the  diseased  portion  removed.     If  the  upper 
extent  of  the  disease  lies  in  relation  to  the  epiphyseal  cartilage,  the  bone 
should  not  be  divided,  but  wrenched  away  from  its  attachment  to  the  epi- 
physis.    When  this  is  done  it  will  be  found  that  the  epiphyseal  cartilage 
remains  attached  to  the  epiphysis.     Much  of  the  success  of  the  operation  is 
based  upon  this  anatomical  fact ;  were  it  otherwise  the  operation  would 
often  be  contra-indicated  on  account  of  the  shortening  which  it  would  entail. 
"  As  long  as  the  epiphyseal  cartilage  is  not  actually  involved  in  the  disease, 
the  operation  does  not  give  rise  to  any  subsequent  shortening."  ^     Subse- 
quent to  the  removal  of  the  bone  there  is  little  bleeding ;  occasionally  the 
main  nutrient  vessel  requires  to  be  tied.     There  is  left  a  flaccid  tube  of 
periosteum,  and  this  is  closed  with  a  series  of  interrupted  catgut  sutures. 
Special  care  is  taken  to  cover  over  the  divided  ends  of  the  bones.     The 
periosteal  tube  fills  with  blood  clot,  and  this,  by  organising,  forms  a  scaffold- 
ing upon  which  new  bone  is  enabled  to  regenerate.     The  regeneration  occurs 
partly  from  the  separated  periosteum  and  partly  from  the  divided  ends  of 
the  bones.     Any  overlying  muscles  and  fasciae  are  united  with  catgut  sutures, 
and   the  skin  edges  are  brought   together   with  silkworm  gut  sutures  or 
Michel's  clips. 

After-treatment. — The  part  must  be  kept  at  rest  in  good  position  for 
some  weeks  after  the  operation.  It  is  sometimes  found,  more  especially 
when  a  single  bone  has  been  removed,  that  the  pull  of  the  overlying  muscles 
tends  to  cruiniile  up  the  lax  periosteum,  and  thus  gives  rise  to  considerable 
shortening.  Tiiis  complication  may  be  avoided  by  applying  extension  to 
the  limb  of  suiHcient  degree  to  overcome  the  muscular  pull.  When  the 
wound  is  firmly  healed,  the  part  is  encased  in  a  light  splint  of  plaster  of  Paris, 
and  this  is  renewed  at  intervals  of  three  months  until  new  bone  formation 
is  completed.  Regeneration  is  usually  complete  at  the  end  of  nine  months. 
Even  when  iciforniation  of  bone  may  appear  complete,  it  is  unwise  to  permit 
full  wciglit-bearing  U|)()n  tlu^  |)art  ;  some  form  of  protection  splint  should 
be  applied  mid  worn  for  about  three  mori'  months. 

•   Stilos,  loc.  sup.  cil.  viil.  ii.  p.  7. 


98  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

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Loewy.     "  Les  Injections  intra-articulaires  dans  les  tumeurs  blanches,"  Par.    chir.,  1910, 

ii.  111-115. 
Belhant.     "  Injections  antiseptiques  dans  les  osteoarthrites  tuberculeuses,"  Ann.  de  chir. 

et  d'orthop.,  Paris,  1911,  xxiv.  65-70. 

Tuberculin  Treatment 
Painter,  C.  F.     "  Experiences  with  Opsonins  and  Bacterial  Vaccines  in  the  Treatment  of 

Tuberculous  and  Non-tulierculous  Arthritis,"  Med.  Communicat.  Mass.  M.  Soc,  Boston, 

1907,  XX.  613-633. 
Dunne,  F.     "  Tuberculou.s  Joint  Disease  treated  with  Denys's  Tuberculin,"  Med.  Press  and 

Circ,  London,  1908,  N.S.,  Ixxxv.  430. 


TREATMENT  OF  BONE  TUBERCULOSIS        99 

Mn.T.En,  H.  B.     "  Opsonic  Therapy  in  Tuberculosis  of  Bones  and  Joints,"  Vniv.  Pcnn.  M. 

Bull,  1908,  xxi.  64-67. 
Freiberg,  A.  H.     "The  Treatment  of  Joint  Tuberculosis  with  Marmorek's  Serum,"  Amer. 

Jmirn.  Orth.  Surg.,  Philadelphia,  1908-9,  vi.  69-78. 
OoiLvy,  C.     "  A  Contribution  to  the  Study  of  Tuberculin  in  Orthopaedic  Practice,"  Amir. 

Journ.  Orth.  Surg.,  1908-9,  v.  35-47. 
NuTT,  J.  J.,  and  Hastings,  T.  W.     "Tuberculin  in  Orthopsedic  Practice."  Amer.  Journ. 

Orth.  Surg.,  1908-9,  vi.  48-68. 
Smith,   M.     "  The  Inoculation  Treatment  of  Tuberculous  Arthritis,"   Brit.   Med.  Journ., 

London,  1909,  ii.  1046-1049. 
OcHSNER,  E.  H.     "  The  Effects  of  Vaccine  Therapy  in  Joint  Tuberculosis,"  Illinois  Med. 

Journ.,  Springfield,  1909,  xv.  137-141. 
RiDLON,     J.       "  Investigations    as    to    the    Value    of    Tuberculin    in    the    Treatment   of 

Tuberculous  Joint  Diseases,"  Trans.  Am.  Ass.  Oenito-Surg.,  N.Y.,  1910,  v.  328-339. 
WiLLiVRD,  De  F.,  and  Thomas,  B.  H.     "  Therapy  by  Bacterins  and  Tuberculins  in  Mixed 

Suppurative  Bone  and  Joint  Disease,"  Ann.  Surg.,  1910,  li.  261-267. 
OcHSNER,  E.  H.     "  Vaccine  Therapy  in  Joint  Tuberculosis,"  St.  Louis  Clinique,  1909,  xxii. 

256-264. 
OcHSSEK,  E.  H.     "  Vaccine  Therapy  in  Joint  Tuberculosis,"  South  M.J.,  Nashville,  1909, 

ii.  445-450. 
SouRDAT,  P.     "  La  Reaction  locale  a  la  tuberculin  dans  les  tuberculoses  ost^oarticulaires," 

Clinigue,  Paris,  1910,  v.  760. 
WiLLARD,  I)E  F.,  and  Thomas,  B.  H.     "  Therapy  by  Bacterins  and  Tuberculins  in  Mixed 

Suppurative  Bone  and  Joint  Disea.se,"   Tr.  Am.  Surg.  Ass.,  Philadelphia,   1910,  xxxiii. 

359-373. 
RiDLON,  J.     "  Investigations  as  to  the  Value  of  Tuberculin  in  the  Treatment  of  Tuberculous 

Bone  Disease,"  Amer.  Journ.  Orth.  Surg.,  1910-11,  viii.  565-577. 
Plimmer,  W.  W.     "  The  \'acciiies  in  Operative  Treatment  of  Tuberculous  Joints,"  Amer. 

Journ.  Orth.  Surg.,  Philadelphia,  1910-11,  viii.  525-537. 
Painter,  C.   F.     "  The  Uses  and  Limitations  of  Vaccine  Therapy  in  the  Management  of 

Arthriti.?,"  Amer.  Journ.  Orth.  Surg.,  Philadelphia,   1910-11,  viii.  538-564. 
Packard,  G.  B.     "  Results  obtained  from  the  Use  of  Tuberculin  in  Joint  Tubercle,"  Amer. 

Journ.  Orth.  Surg.,  1911-12,  ix.  17-24. 
Porter,  J.  L.,  and  Quinn,  L.  C.     "  The  Treatment  of  Tuberculous  Joint  Disease  with  Karl 

Spcngler's  I.K.  Serum,"  Chicago  j\[.  Hecnrd,  1912,  xxxiv.  84-91. 
Silver,   D.      "  Vaccine  Therapy  in  Tuberculous    Bone    and  Joint  Disease,"   Penn.   M.J., 

Athens,  1912,  xvi.  219-223." 
EvERSOLE,  H.  0.     "  The  Use  of  Karl  Spengler's  I.K.  Serum  in  the  Treatment  of  Tuberculous 

Joint  Disease,"  Amer.  Journ.  Orth.  Surg.,  1912-13,  x.  234-242. 
Gillespie,  E.     "  The  Results  of  P.T.O.  in  Tuberculous  Bone  and  Joint  Ijesions,"  Journ. 

Vaccine  Therajn/,  1913,  ii.  91-101. 
Prevost  and   Depos.     "  Traitement  de  la  tubcrculoso  osseuse  par  les  paratoxines,"  Jiei: 

mod.  de  mid.  et  de  chir.,  Paris,  1912,  x.  55-58. 

Treatment  of  Bone  Cavities 

CoDET-BoissE.     "  Le  Traitement  des  cavit(5s  osseuscs  par  la  methode  do  Mosetig,"  Journ. 

de  med.  de  Bordfaux,  1908,  xxxviii.  821-824. 
CoLLENET,  A.     Ciintril>uli(>n  a  l' etude  de  V obliteration  des  caviles  osseuses  par  le  melange  de  von 

Mnsetig-Monrhof,  Lyon,   1908. 
Hn.L,  R.     "The  Treatment  of  Bono  Cavities,"  Mobile  M.  and  S.J.,  1908.  xii.  41-48. 
Walton,  A.  J.     "  Cases  of  Bone  Cavities  treated  by  stopping  with  Paraffin,"  Lancet,  London, 

1908,  i.  155-157. 
VVetiiehill,  H.  G.     "  Bone  Cavities  and  Interspaces  and  their  Treatment,"  Colorado  Med., 

Denver,  1908,  v.  9-15. 
Le  Breton,  P.     "Some  Experimental  Work  with  Materials  for  Plugging  Sinuses  and  Bono 

Cavities,"  Amer.  Journ.  Orth.  Surg..  1909-10.  vii.  464-468. 
Sherman,  H.  M.     "Salt  Solution  as  a  Killing  for  Bone  Cavities,"  Surg.  Oyn.  and  Obst..  191 1. 

xiii.  147-151. 
Machahi).      "  Traitement    des   cavitds   tuberculousos   ostdoarticulaires    par   lo    proc6d<5    do 

Mosetig,"  liev.  med.  de  In  Suisse  rom.,  Geneve,  1912,  xxxii.  797-802. 


100  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


TREATMENT  OF  JOINT  TUBERCULOSIS 

It  is  unnecessary  to  deal  with  preventive,  general,  or  tuberculin  treat- 
ment. These  have  been  already  discussed  in  application  to  bone  tubercu- 
losis, and  their  conduction  is  exactly  similar  in  joint  disease.  Conservative 
and  operative  treatment,  upon  the  other  hand,  have  more  special  applica- 
tions, and  they  require  to  be  considered. 

Conservative  Treatment 

A  number  of  methods  are  included  under  the  "  Conservative 
treatment."     The  following  will  be  dealt  with  : 

Fixation.  Counter- irritation.  Hypersemia. 

Extension.  Injection. 

Fixation  Treatment. — This  will  be  discussed  under  three  headings  : 
(1)  The  stage  of  absolute  fixation  of  the  joint ;  (2)  The  stage  of  partial 
fixation,  in  which  slight  movement  is  permitted,  but  no  weight-bearing  ; 
(3)  The  final  stage,  in  which  moderate  weight-bearing  is  allowed,  but  the 
extremes  of  movement  are  curtailed. 

(1)  Absolute  Fixation. — As  in  bone  tuberculosis,  absolute  fixation  of  the 
part  must  be  put  in  the  forefront  of  conservative  treatment.  The  materials 
which  may  be  suitably  used  are  less  numerous  than  in  the  treatment  of 
osseous  disease,  because  there  are  only  certain  substances  which  are  suffi- 
ciently and  completely  adaptable.  Of  the  available  material  a  premier 
position  must  be  given  to  plaster  of  Paris,  applied  by  the  method  already 
described.  A  casing  of  sufficient  thickness  is  used,  and  while  still  soft  it  is 
moulded  with  the  hand  to  the  outlines  of  the  enveloped  joint.  Celluloid 
makes  an  excellent  fixation  splint,  but  it  necessitates  the  taking  of  a  cast 
and  a  prolonged  preparatory  process.  A  well-fitting  celluloid  splint  provides 
absolute  fixation,  with  the  minimum  of  weight  and  the  greatest  possible 
degree  of  comfort.  Splints  of  wood  and  metal  are  not  suitable.  They  are 
not  readily  adaptable  to  the  joint  outline  unless  they  have  been  thoroughly 
padded,  and  when  padded  they  often  lose  a  considerable  degree  of  their 
fixing  power. 

In  applying  the  fixation  splint,  two  principles  must  be  kept  in  view. 
The  first  is  that  it  is  not  sufficient  to  fix  merely  the  joint  afl'ected.  It  is 
essential  that  the  joints  immediately  above  and  below  should  also  be 
rendered  rigid.  This  may  necessitate  considerable  increase  in  the  size  of 
the  splint.  The  second  essential  is  in  regard  to  the  position  of  the  limbs, 
when  the  splint  is  in  position. 

The  cure  of  a  tuberculous  joint  sometimes  necessitates  ankylosis  of  the 
joint,  and  it  is  all-important  that  the  ankylosis  should  occur  in  a  position 
most  useful  to  the  patient.     Therefore,  when  a  fixation  splint  is  necessary, 


TREATMENT  OF  JOINT  TUBERCULOSIS 


101 


it  ought  to  be  applied  with  the  joiiit  in  such  a  position  that  if  ankylosis  occurs 
the  sacrifice  of  limb  function  is  reduced  to  a  minimum.  This  point  is  dealt 
with  fully  in  application  to  the  individual  joints. 

Joints  treated  in  this  way  are  in  a  condition  of  absolute  fixation,  and 
depending  on  the  position,  size,  and  weight-bearing  necessities  of  the 
joint,  the  treatment  will  extend  over  a  period  varying  from  six  months  to 
several  years.  At  the  termination 
of  this  period  the  second  stage 
of  fixation  treatment  is  entered 
upon. 

(2)  Partial  Fixation.  —  The 
fixation  is  no  longer  absolute,  a 
slight  degree  of  movement  is  pos- 
sible, but  all  idea  of  weight- 
bearing  is  rigidly  avoided.  To 
secure  this  effect,  numerous  splints 
have  been  devised  for  individual 
joints,  and  this  is  the  principle 
upon  which  the  well  -  known 
Thomas's  hip  and  knee  splints  are 
based.  The  duration  of  the 
second  stage  of  treatment  varies 
according  to  the  joint  affected.  A 
suitable  average  period  is  one  of 
six  months. 

(3)  Final  Stage. — Lastly,  one 
enters  on  the  final  stage  in 
fixation  treatment.  Movement  is 
now  permitted,  but  within  limits. 
The  extreme  movements  of  the 
joint  are  avoided;  weight-bearing 

is  begun,  at  first  in  a  slight  degree,     Fia.  6.— Three  possible   methods  of  applying  ex- 

and    then    gradually    increasing.  ension  p  as  ers. 

■..  r  1  •       1  .       .1.  A  single  strip  is  applied  to  the  limb  on  each  .side. 

Very     often     this     last     stage     is     /;.   Lateral  strips  are  applied  with  a  circular  turn 

above  the  ankle-joiut. 
C.    Each  lateral  strip  has   three    subdivisions  ;  the 

outer  ones  are  wound  spirally  arouml  tlie  limb, 


neglected,  but  if  it  is  adopted 
the  joint  is  fitted  with  a  light 
retentive  apparatus,  usually  of 
leather,  which  prevents  the  more  extensive  of  the  joint  movements. 

Treatment  by  Extension. — A  diseased  joint  may  be  in  such  a  con- 
dition that  it  cannot  be  immediately  placed  in  a  position  of  absolute 
fixation,  and  a  preliminary  period  of  treatment  by  extension  becomes 
necessary.  There  are  two  conditions  which  give  rise  to  the  necessity  : 
the  presence  of  pain  in  the  joint  with  muscular  spasm,  and  deformity  of 
the  joint  due  to  irregular  muscular  contraction. 

Extension  is  apjjlicd  to  the  limb  by  elastic  tension  or  by  weight.  The 
latter  method  is  preferable,  as  its  amount  can  be  easily  varied  at  will.     The 


102  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

actual  application  is  made  in  different  ways.  Some  form  of  adhesive 
strapping  is  applied  to  the  limb,  it  may  be  in  the  form  of  single  lateral 
strips,  or  in  the  more  complicated  form  originated  by  Taylor.  In  the 
Edinburgh  Children's  Hospital  a  modification  of  Taylor's  method  is  used. 
Its  application  is  simple,  and  may  be  understood  by  reference  to  Fig.  6,  C. 

Before  applying  the  strapping  the  limb  should  be  shaved,  and  any  bony 
prominence  over  which  the  extension  may  play  ought  to  be  protected  by 
small  pads  of  lint.  To  the  lower  end  of  the  adhesive  strapping,  tapes  are 
stitched,  and  to  the  tapes,  weights  are  attached  through  the  medium  of  an 
ordinary  wooden  stirrup.  The  weight-cord  runs  over  a  pulley,  the  position 
of  which  can  be  altered  at  will.  Fig.  99  illustrates  a  useful  form  of  pulley- 
holder,  which  can  be  attached  to  most  varieties  of  cots.  The  amount  of 
weight  varies  with  three  factors  :  the  age  of  the  child,  the  degree  of  muscular 
development,  and  the  pathological  condition  which  necessitates  the  use  of 
the  weight.  During  the  first  three  years  of  life  it  is  often  stated  that  a 
pound  is  added  for  each  year.  Above  three  years  the  proportion  cannot  be 
increased  so  rapidly.  The  muscular  strength  varies  enormously,  and  it  must 
be  carefully  considered  in  judging  the  degree  of  weight  required.  The  type 
of  lesion  is  a  most  important  consideration.  If  extension  is  applied  on. 
account  of  pain  in  the  joint,  the  pain  resulting  from  muscular  contraction 
and  tissue  destruction,  a  comparatively  small  amount  of  weight  is  sufficient 
to  relieve  the  symptoms.  But  if  the  extension  is  being  used  to  correct  a 
joint  deformity,  a  much  greater  weight  becomes  necessary. 

It  is  important  to  apply  the  extension  in  the  actual  axis  which  the  limb 
occupies.  If  this  is  a  deformed  axis  it  does  not  matter,  because  by  extend- 
ing, first  in  the  deformed  position  and  gradually  bringing  the  axis  towards 
the  normal  one,  the  deformity  is  overcome. 

A  warning  must  be  given  in  regard  to  the  danger  of  using  too  much 
weight.  Joint  pain  which  is  not  relieved  by  extension  often  means  an 
excessive  degree  of  weight,  and  when  this  is  reduced  the  relief  may  be 
immediate.  Excessive  weight  application  also  tends  to  stretch  ligaments 
and  weaken  joints,  and  even  to  produce  some  separation  of  epiphysis. 

Counter  extension  may  be  necessary,  the  weights  being  applied  in  op- 
posite directions.  The  weight  of  the  body  may  be  used  instead  of  a  second 
application  of  weights,  as,  for  example,  in  the  extension  used  in  lower  spine 
Pott's  disease,  in  which  weights  are  applied  to  the  lower  limbs,  and  the  foot 
of  the  bed  raised.  In  certain  cases,  second  extension  must  not  be  applied 
as  a  true  counter  or  opposite  extension,  but  as  an  oblique  or  right-angled 
extension  ;  for  example,  in  tuberculous  disease  of  the  hip-joint,  simple  exten- 
sion in  the  long  axis  of  the  femur  may  not  relieve  the  symiDtoms,  because 
the  lower  part  of  the  head  is  pressing  against  the  rim  of  the  acetabulum. 
There  is  immediate  relief  when  a  second  extension  is  carried  out  at  right 
angles  to  the  first  in  the  axis  oi  the  neck  of  the  femur. 

Counter-irritation  of  Joint. — Many  authors  have  drawn  attention 
to  the  marked  benefit  which  appears  in  joint  symptoms  after  the  application 
to  the  joint  of  some  form  of  counter-irritation.     There  is  almost  universal 


TREATMENT  OF  JOINT  TUBERCULOSIS  103 

agreement  that  the  best  way  in  which  to  apply  the  counter-irritation  is  by 
means  of  the  actual  cautery.  Heated  to  a  black  heat,  a  broad  cautery  is 
applied  momentarily  to  the  skin  over  the  affected  joint.  Blisters  form, 
and  are  suitably  dressed.  Other  counter-irritants,  and  more  especially 
tincture  of  iodine,  have  been  recommended.  It  is  rarely  that  the  reaction 
they  produce  is  sufficient  to  give  rise  to  any  symptomatic  improvement. 

Injection  of  the  Joint  Cavity  and  its  Surroundings. — Medicated 
injections  are  among  the  accessories  of  local  treatment.  They  are  intro- 
duced into  the  interior  of  the  joint  or  into  the  thickened  tuberculous  tissue 
around.  When  the  injection  is  made  into  the  interior  of  the  joint,  the  solu- 
tion is  distributed  as  completely  as  possible  over  the  synovial  surface.  The 
fluid  contents  a^e^^^thdrawn,and  the  medicament  introduced  through  a  single 
puncture.  The  technique  is  exactly  similar  to  that  described  in  the  account 
of  the  treatment  of  a  cold  abscess.  When  the  injection  is  made  into  the  peri- 
articular tissues,  small  amounts  are  introduced  through  a  number  of  separate 
punctures. 

Solutions. — A  favourite  solution  to  employ  is  a  sterile  emulsion  of  10 
per  cent  iodoform  in  glycerin.  It  produces  a  benefit  in  cases  in  which  the 
synovial  membrane  only  is  affected  ;  it  is  useless  when  the  bone  is  diseased. 
A  disadvantage  is  the  intense  reaction  which,  more  especially  in  children, 
sometimes  follows  its  employment.  There  is  a  local  reaction  in  the  joint 
— pain  and  swelling.  But  the  general  reaction  is  of  more  import ;  it  consists 
in  symptoms  of  fever,  headache,  malaise,  rash,  and  unfortunately  sometimes 
the  graver  symptoms  of  sickness,  delirium,  and  haematuria. 

Iodoform  in  ether,  5  or  10  per  cent,  is  used  less  commonly  than  the 
glycerin  emulsion.  It  possesses  the  disadvantages  common  to  all  iodoform 
preparations,  and  in  addition  the  special  disadvantage  of  the  volatility 
of  its  ether,  which  sometimes  distends  the  joint  to  a  dangerous  degree. 

Calot  recommends  the  use  of  naphthol-camphor  and  creasote-iodoform 
solutions.  He  distinguishes  two  varieties  of  tuberculous  joints  from  the 
point  of  view  of  injection  treatment :  {a)  tuberculous  joints  with  effusion, 
and  (6)  dry  tuberculous  joints.  The  former  he  treats  exactly  upon  the  line 
of  a  cold  abscess.  Creasote  and  iodoform  emulsion  is  injected  at  intervals 
of  six  or  eight  days,  over  a  period  extending  in  all  to  two  months.  In  the 
dry  form  of  tuberculous  joint  he  offers  a  choice  of  two  modes  of  cure  : 

(1)  By  producing  a  simple  sclerosis  without  effusion.  This  he  secures 
by  injecting  once  a  week  for  eight  or  nine  weeks  a  quantity  of  the  iodoform- 
creasote  emulsion.  The  amount  injected  varies  from  2  to  12  grammes, 
according  to  the  age  of  the  child  and  the  capacity  of  tlie  joint. 

(2)  In  the  second  metiiod  the  object  is  to  produce  an  effusion  into  the 
joint,  and  this  is  secured  by  using  the  naphthol-camphor  solution  (1  gramme 
naphtliol-rainj)hor  to  5  grammes  of  glycerin).  The  amount  injected 
varies  from  (J  to  .'50  drops,  and  the  treatment  is  continued  each  day  until  an 
effusion  appears  into  the  joint.  When  an  effusion  appears  the  joint  is  treated 
as  in  class  I . 

Hyperaemic  Treatment. — A  tuberculous  joint  was  the  first  disease  to 


104 .  TUBERCULOSIS  OP  THE  BONES  AND  JOINTS 

which  Bier  applied  his  hyperfemic  treatment.  He  recommends  only  the 
passive  method  of  treatment,  as  he  considers  that  symptoms  tend  to  become 
aggravated  by  the  use  of  an  active  hyperaemia.  At  first  Bier  applied  hyper- 
semia  for  a  prolonged  period  on  each  appUcation,  but  he  found  that  this 
induced  the  formation  of  large  cold  abscesses  and  quantities  of  fungating 
granulation  tissue.  To  avoid  these  complications  he  altered  his  regime.  The 
treatment  was  begun  by  aj^plying  the  bandage  for  a  period  of  eight  or  ten 
hours  a  day,  gradually  reducing  the  time,  until  at  the  end  of  a  few  weeks  only 
one  hour's  application  was  made  each  day.  The  change  produced  a  decided 
improvement,  but  cold  abscesses  continued  to  form,  though  perhaps  with  less 
persistency.  Bier  now  makes  use  of  the  method  employed  by  Tilmann  in 
the  Greifswald  Surgical  Polyclinic  :  a  method  in  which  he  applies  the  con- 
gestion treatment  only  one  hour  daily.  Por  this  period  it  is  permissible  to 
allow  the  hyperemia  strongly  to  afiect  the  limb,  but  the  bandage  must  not 
be  applied  tightly  enough  to  cause  pain  or  pareesthesia  in  the  treated 
extremity.  If  the  joint  lesion  is  an  especially  intractable  one,  an  hour  daily 
is  too  short  a  period  ;   two  or  even  three  hours  may  be  necessary. 

Cold  Abscesses  and  Sinuses. — When  cold  abscesses  and  sinuses 
develop,  they  are  treated  by  the  methods  already  described. 

Summary  of  Treatment. — In  concluding  this  outline  of  the  con- 
servative treatment  of  tuberculous  joints,  it  will  be  well  to  mention  the 
sequence  one  follows  in  employing  the  different  methods  of  treatment. 
When  the  joint  first  comes  under  treatment,  if  there  is  much  pain  or  any 
degree  of  deformity,  weight  extension  is  applied  until  the  pain  disappears 
or  the  deformity  is  corrected.  The  joint  is  then  placed  at  absolute  rest,  in 
the  most  suitable  position — the  most  suitable  should  ankslosis  occui'.  While 
it  is  kept  at  rest  the  auxiliary  treatment  of  hyperaemia  or  medicated  injection 
may  be  used.  If  plaster  of  Paris  is  employed  to  secure  the  complete  fixation, 
and  it  is  intended  to  employ  joint  injection  in  addition,  suitable  windows 
will  require  to  be  cut  out  of  the  plaster  over  the  joint  to  allow  the  injections 
to  be  made.  When  the  hypersemic  treatment  is  to  be  used  in  conjunction 
with  fixation,  plaster  is  not  so  suitable,  as  the  swelling  of  the  part  may  be 
too  intense. 

The  fixation  material,  plaster  or  whatever  it  may  be,  is  changed  at 
intervals  of  three  months,  and  on  the  occasion  of  each  successive  change 
it  is  advisable  to  have  the  part  X-rayed  in  order  to  record  the  progress  which 
is  being  made.  At  each  interval  it  is  important  carefully  to  examine  the 
joint  for  the  formation  of  a  cold  abscess.  This  applies  more  especially  to  such 
deeply  situated  joints  as  the  hip,  in  which  a  cursory  examination  may  easily 
overlook  a  small  collection  of  pus.  The  period  of  complete  fixation  will 
extend  upon  an  average  over  twelve  months.  A  further  period  of  time  is 
spent  in  some  form  of  ambulatory  apparatus,  and  then  the  joint  is  allowed 
to  perform  limited  movements,  unless  of  course  the  cure  has  been  accom- 
panied by  ankylosis. 


TEEATMENT  OF  JOINT  TUBERCULOSIS  105 

Operative  Treatment 

Indications  for  Operation. — The  indications  for  operative  treatment 
are  very  similar  to  those  discussed  in  regard  to  bone  tuberculosis.  Nothing 
can  be  added  in  regard  to  the  questions  of  age  and  family  history.  The 
social  condition  of  the  patient  is  even  a  more  important  guide  than  it  is  in 
bone  tuberculosis. 

A  tuberculous  joint  interferes  with  movement  and  locomotion  more 
completely  than  a  tuberculous  bone  ever  can,  and  when  the  disease  appears 
in  the  joint  the  whole  limb  is  crippled.  You  give  the  patient  a  choice  of  a 
period  of  conservative  treatment,  extending  over  many  months,  with  perhaps 
a  movable  joint  at  the  end  of  that  time  ;  or  an  operation,  a  period  of 
post-operative  treatment,  and  a  stiff  joint.  Among  the  classes  from  which 
hospital  patients  are  drawn  the  tendency  is  to  choose  the  latter  alternative. 

The  joint  affected  is  of  premier  consideration.  In  the  knee-joint  the 
results  of  operation  are  so  good  that  one  has  little  hesitancy  in  recommending 
it ;  but  in  such  a  position  as  the  wrist-joint  one  prefers  to  persevere  with 
conservative  measures. 

Lastly,  there  are  indications  in  regard  to  the  clinical  features.  One 
should  take  into  consideration  the  duration  of  conservative  treatment 
which  has  been  already  attempted,  the  development  of  cold  abscesses 
and  sinuses,  and  the  appearance  of  bone  foci  as  demonstrated  by  X-rays. 
There  are  special  indications  for  individual  joints,  and  these  will  be  dealt 
with  separately. 

Types  of  Operation 

The  operative  measures  to  be  considered  are  : 
Arthrotomy  and  Curetting.  Ajcthrectomy.  Amputation. 

Synovectomy.  Excision. 

Arthrotomy  and  Curetting-. — There  are  cases  in  which  there  can  be 
demonstrated  a  small  localised  area  of  disease  in  the  synovial  membrane 
or  in  the  underlying  bone.  By  removing  this  single  focus,  it  may  be  possible 
to  completely  arrest  the  disease,  and  at  the  same  time  obviate  the  necessity 
for  any  prolonged  after-treatment.  The  joint  is  opened  by  a  suitable 
incision,  and  the  diseased  tissue  cut  out  or  curetted  away.  The  cavity  is 
touched  with  absolute  alcohol,  containing  10  parts  of  carbolic  acid,  and  the 
wound  is  closed  witiiout  drainage.  The  operation  should  be  followed  by 
traction  upon  the  limb,  and  the  after-treatment  should  include  a  period  of 
absolute  fixation. 

Synovectomy,  Arthrectomy,  and  Excision.  -These  three  procedures 
may  be  considered  together. 

Synoveclomy.  —  Theoretically,  synovectomy  is  a  removal  of  the 
synovial  membrane,  without  interfering  in  any  way  with  the  underlying 
cartilage  or  bone.  The  joint  is  freely  opened,  and  the  diseased  membrane 
clipped  away  with  a  pair  of  scissors  curved  on  the  flat.  Natunilly  the 
indications  calling  for  such  an  operation  arc  exceedingly  limited,  and  as  an 


106  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

operation  it  carries  with  it  the  risk  of  recurrence,  because  in  a  complicated 
joint  it  may  be  impossible  entirely  to  remove  synovial  membrane  and 
synovial  membrane  only. 

Arthrectomy . — Arthrectomy  may  be  looked  upon  as  a  further  stage  of 
synovectomy,  but  instead  of  restricting  one's  attention  to  the  membrane,  a 
layer  of  the  underlying  cartilage  is  removed.  The  bone  is  not  exposed, 
and  thus  there  is  not  the  same  tendency  to  ankylosis.  As  an  operation,  a 
pure  arthrectomy  is  frequently  indicated,  and  the  results  obtained  are  often 
excellent.  It  possesses  the  advantage  of  not  necessarily  being  followed  by 
ankylosis. 

Excision. — Excision  is  the  dernier  ressort  of  the  local  removal  treat- 
ment. The  entire  joint-bearing  surface  is  removed,  all  the  intricacies 
of  the  synovial  arrangement  are  followed  out,  and  the  underlying  bone 
surfaces  are  exposed.  As  an  operation  it  is  indicated  in  cases  too  extensive 
to  permit  of  arthrectomy,  in  which  there  is  disease  of  the  subarticular  bone. 
When  the  procedure  is  thoroughly  carried  out,  recurrence  of  the  disease  is 
rare.  It  has  one  distinct  disadvantage,  and  one  -which  may  be  a  possible 
disadvantage.  The  first  is  the  shortening  which  necessarily  results  in  the 
limb,  most  marked  when  the  epiphyseal  cartilage  is  destroyed.  The  second 
possible  disadvantage  is  the  osseous  ankylosis  which  is  so  likely  to  result. 
In  many  joints  this  latter  is  looked  upon  as  an  advantage  rather  than  a 
disadvantage,  e.g.  the  knee-joint. 

Amputation. — The  question  of  amputation  of  the  diseased  limb  remains 
for  consideration.  It  is  indicated  when  there  is  steady  progression  of  the 
disease,  mixed  infection  with  sinus  formation,  and  a  general  health  decline 
from  waxy  disease  and  cachexia.  The  mutilation  which  results  is  the  chief 
objection  to  the  operation.  It  is  most  important  not  to  delay  amputation 
too  long,  and  in  the  actual  technique  of  the  operation  one  must  avoid  the 
danger  of  encroaching  upon  the  diseased  area,  and  so  running  the  risk 
of  tuberculous  infection  of  the  flaps.  The  operation  is  described  under 
the  head  of  each  individual  joint. 

Correction  of  Deformity. — As  the  result  of  neglect  or  improper  treat- 
ment, tuberculous  joints  may  become  fixed  in  deformed  positions.  The 
deformity  is  at  first  the  result  of  a  muscular  contraction,  and  usually  the 
greater  power  of  the  flexors  decides  that  the  deformity  is  one  of  flexion. 
In  the  later  stages  adhesion  between  the  joint  surfaces  renders  the  alteration 
in  position  more  permanent  in  character.  The  deformity  may  be  corrected 
by  conservative  or  by  operative  means. 

Conservative  Treatment. — The  conservative  measures  adopted  may  be 
gradual  or  immediate. 

(fl)  Gradual. — Speaking  generally,  it  may  be  said  that  gradual  correction 
is  obtained  by  some  form  of  extension.-  The  variety  may  vary  within  wide 
limits.  It  may  be  accomplished  by  head  or  by  foot  extension,  by  horizontal 
extension  in  the  hip  and  knee,  first  in  the  line  of  the  deformity,  then 
gradually  towards  normal,  by  fastening  the  bent  limb  to  a  straight  frame,  as 
in  the  spine,  or  by  a  series  of  plaster  of  Paris  fixations  in  improved  positions. 


TREATMENT  OF  JOINT  TUBERCULOSIS  107 

It  is  unnecessary  to  give  more  exact  details  at  this  point,  as  they  are  dis- 
cussed under  the  individual  joints. 

(6)  Immediate. — Under  a  general  anaesthetic,  a  cautious  and  experienced 
surgeon  can  secure  great  improvement  in  the  position  of  a  deformed  joint 
by  gradually  straightening  the  part  and  fixing  it  in  the  corrected  position. 
Myotomy  of  shortened  muscles  may  be  necessary  before  complete  correction 
can  be  obtained. 

Operative  Treatment. — Different  operative  procedures  are  adopted  in 
different  joints.  A  complete  division  of  shortened  soft  parts  may  be  suffi- 
cient. Frequently  it  becomes  necessary  to  divide  the  bone  by  a  transverse 
or  a  cuneiform  osteotomy. 

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i.  615-619. 
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Gradmte,  New  York,  1909,  xxiv.  840-844. 
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Disease  of  Joints,"  Brit.  M.  Journ.,  London,  1909,  ii.  949-956. 
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1909,  V.  250-254. 

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Monatsschr.  f.  d.  phys.  DiateK,  Hcllmcth.  1910. 
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1910,  ciii.  485-489. 

Baden,  C.     "  Le  Traitement  des  exudates  inflammatoires  et  de  la  tuberculose  osseuse  par 

isolation,"  Clinique,  Paris,  1910,  v.  218. 
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1910-11,  Ixiii.  151-154. 
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Perthes,  G.     "  tjber  die  Behandlung  der  Knochen-  und  Gelenktuberkulose,"   Therap.  d. 

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PAPiT   II.-SPECIAL 


TUBERCULOUS  DISEASE  OF  THE  SPINE 

The  vertebrae  are,  of  all  ther  bones,  the  most  liable  to  tuberculous  infection, 
and  as  the  spinal  column  is  the  axis  upon  which  the  whole  osseous  arrange- 
ment depends,  the  importance  of  a  spinal  infection  cannot  be  overestimated. 
It  is  calculated  that  one-fifth  of  all  cases  of  bone  disease  have  their  seat  in 
the  spine  ;   it  is  slightly  more  common  in  boys  than  in  girls. 

Etiology 

The  condition  is  essentially  due  to  infection  of  the  vertebrae  \sith  tubercle 
bacilli.  The  method  by  which  the  infection  gains  admission,  and  the  changes 
which  the  organism  produces,  are  discussed  under  pathology,  but  there  are 
certain  features  bearing  upon  the  etiology  which  must  now  be  considered. 

Age. — The  disease  is  most  common  in  children,  and  probably  its  most 
frequent  incidence  is  found  during  the  first  five  years  of  life.  Lannelongue  ^ 
has  given  statistics  gained  from  a  study  of  180  cases  occurring  in  children 
under  sixteen  years  old.  In  7  per  cent  of  the  cases  the  disease  first  appeared 
when  the  child  was  less  than  two  years  old.  Between  two  years  and  five 
years  no  less  than  50  per  cent  of  the  cases  occurred.  In  the  period  from 
five  years  to  ten,  32  per  cent  of  the  cases  could  be  placed.  The  remaining 
10  per  cent  occurred  over  ten  years  of  age.  It  is  generally  acknowledged, 
and  all  statistics  support  the  fact,  that  five  years  of  age  is  the  most  common 
period  at  which  the  disease  appears. 

Sex. — Sex  does  not  appear  to  be  a  factor  of  any  importance.  The 
disease  is  slightly  more  common  in  boys  than  in  girls,  but  according  to 
Wiillstein  ^  the  proportion  is  wonderfully  equal :  53-29  per  cent  males  and 
46-71  females. 

Injury.-  It  is  quite  certain  tiiat  in  the  history  of  a  number  of  cases 
one  finds  some  account  of  an  injury,  in  particular  a  fall  from  some  small 
height.  From  what  one  knows  of  the  pathology,  it  is  possible  that  accident 
does  play  its  part  in  originating  the  disease,  but  too  often  the  history  of 
injury  is  more  imaginary  than  real.  It  is  a  slight  injury  rather  more  than 
a  severe  one  which  predisposes  to  the  disease. 

'   I-iimicloiiKuc,  Tuherruloim    Vertchrnls,  ji.  1.17. 

-  W'lilLsU-in,  J oachi mnlhaV a  Chir.  Ortli.,  Part  I. 

Ill 


112  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

Heredity. — Tuberculosis  is  so  common  and  so  widespread  that  it  is 
never  very  difficult  to  trace  its  ravages.  In  Pott's  disease,  as  in  tuberculosis 
elsewhere,  there  is  usually  a  tuberculous  family  history.  Gibney  ^  found 
that  76  per  cent  of  cases  showed  a  family  history  of  tubercle — in  38  per  cent 
on  the  mother's  side,  in  35  per  cent  on  the  father's  side,  in  31  per  cent 
on  both  sides.  Statistics  published  by  Waterman  and  Jaeger  ^  differ 
considerably  from  these.  According  to  them  only  10  per  cent  of  the  children 
were  born  of  tuberculous  parents. 

There  are  other  subsidiary  facts  in  the  predisposing  etiology.  One 
frequently  finds  the  disease  coming  on  after  an  attack  of  one  of  the  exan- 
themata ;  the  predisposition  is  due  to  a  lowering  of  the  body  vitality. 
Then  there  is  the  fact  of  tuberculosis  elsewhere.  Vertebral  tuberculosis  is 
rarely  a  primary  manifestation.  Autopsy  usually  reveals  a  primary  focus 
in  some  other  part,  most  commonly  in  the  bronchial  or  mesenteric  glands. 

In  regard  to  the  association  of  other  bone  and  joint  lesions  with  Pott's 
disease,  one  is  thoroughly  in  agreement  with  Tubby  *  when  he  says  :  "At 
the  Evelina  Hospital  for  children  we  have  often  observed  the  sequence  of 
events  :  tuberculous  dactylitis,  glands,  coxitis,  or  other  varieties  of  arthritis, 
persisting  for  some  months  or  a  year,  and  then  the  onset  of  spinal  caries. 
Very  rarely  is  the  reverse  order  of  events  met  with." 


Pathology 

The  Localisation  of  the  Disease. — The  majority  of  authorities  are 
agreed  that  the  lower  dorsal  portion  of  the  spine  is  the  part  most  frequently 
affected.  This  rule  of  location  is,  however,  not  universally  accepted. 
Thorndike ''  holds  that  the  proportion  of  occurrence  is  that  of  one  cervical 
for  three  dorsal  and  five  lumbar  cases  ;  but  he  adds  that  in  New  York,  out 
of  1000  cases  6-6  per  cent  were  cervical,  70-9  per  cent  dorsal,  and  22-5  per 
cent  lumbar. 

As  regards  the  individual  vertebrae  affected,  the  most  common  are  those 
from  the  eighth  dorsal  to  the  first  lumbar,  vertebrae  which  require  to  stand 
greater  superincumbent  weight  than  any  others  in  the  spinal  column. 

General  Structure  of  Vertebrae. — The  anterior  portion  of  each 
vertebra  is  formed  by  the  large  rounded  body,  filled  with  cancellous 
tissue,  and  bounded  above  and  below  by  the  discs  of  the  intervertebral 
cartilages.  From  the  postero- lateral  aspects  of  the  bodies  there  project 
backwards  the  two  pedicles,  which  with  the  two  transverse  processes,  the 
articular  processes,  the  two  laminae,  and  the  spinous  process,  complete 
the  vertebrae,  and  enclose  the  spinal  canal. 

With  the  exception  of  the  atlas  and  axis  vertebrae,  all  the  vertebrae  of 
the  column  may  be  said  to  be  articulated  upon  the  same  scheme.     Three 

'  Quoted  by  Bradford  and  Lovett,  Orth.  Surg.,  p.  11. 

-  Trans.  Amer.  Orth.  Surg.,  1901,  vol.  xiv.  p.  287. 

'  Deformities,  including  Diseases  of  the  Bones  and  Joints,  1912,  vol.  ii.  p.  .57. 

*  Thorndike,  Ortliopa'dic  Surgery,  1907,  p.  208. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  113 

separate  joints  exist  between  opposing  bodies,  a  central  amphiarthrodial 
joint,  and  two  lateral  diarthrodial  joints.  The  amphiarthrodial  joint 
occupies  the  greater  part  of  the  space  between  the  vertebral  bodies,  where 
the  two  bone  surfaces  are  brought  into  contact  by  a  layer  of  fibrocartilage. 
Between  the  opposing  articular  processes  there  are  joints  of  the 
diarthrodial  variety.  The  ligaments  which  bind  the  bodies  together  are 
the  anterior  common  ligament  in  front  of  the  vertebral  bodies,  the 
posterior  common  ligament  which  lies  on  the  posterior  aspect  of  the 
vertebral  bodies,  and  the  various  interspinous  and  intertransverse  ligaments, 
with  the  ligamenta  subflava  between  the  adjacent  lamina?. 

It  is  unnecessary  to  describe  the  distinct  and  numerous  articulations 
between  the  axis,  atlas,  and  occipital  bones.  All  the  joints  are  of  the 
diarthrodial  variety. 

Blood  Supply  of  Vertebrae. — The  largest  amount  of  the  blood  supply 
is  distributed  to  the  interior  of  the  body  of  the  vertebra.  The  vessel  is 
derived  from  the  posterior  spinal  artery,  and  it  enters  the  body  by  one  or 
two  distinct  foramina  upon  the  centre  of  the  posterior  surface.  Narrow 
zones  of  bone  at  the  attachment  of  each  intervertebral  cartilage  upon  the 
upper  and  lower  surfaces  of  the  body  derive  special  blood  supplies  from 
what  are  termed  the  epiphyseal  arteries,  derived  from  the  posterior  spinal 
artery.  An  area  of  bone  in  the  front  of  the  body  obtains  its  blood  from 
branches  of  the  intercostal  arteries.  Each  vertebral  body  therefore  has 
four  distinct  sources  of  blood  supply.  At  the  base  of  each  transverse 
process  a  separate  vessel  on  each  side  penetrates  the  front  of  the  process 
at  its  junction  with  the  pedicle.     It  owes  its  origin  to  the  intercostal  vessels. 

The  scheme  of  blood  supply  is  distinct  in  the  atlas  vertebra.  It  pos- 
sesses no  proper  body,  and  therefore  the  large  central  artery  is  absent.  Its 
place  is  taken  by  two  lateral  vessels,  which  enter  one  from  each  side  and 
run  forwards  and  backwards  within  the  bone. 

Pathologry. — The  infection  is  carried  by  the  blood  stream  into  the 
bone,  and,  according  to  the  distribution  of  the  vessel,  different  areas  are 
infected  by  the  disease.  (1)  It  may  occur  in  the  centre  of  the  vertebral 
body,  and  this  constitutes  by  far  the  greatest  proportion  of  the  cases.  It 
may  be  spoken  of  as  ihc  central  variety.  (2)  'IMic  infection  may  begin  at 
the  epij)hysis  of  the  body,  beside  the  attachment  of  the  intervertebral  disc. 
From  the  epiphysis  it  extends  into  the  body  of  the  vertebra  or  into  the 
8ub.stance  of  the  di.sc  :  the  epiphyseal  varietij.  (3)  The  anterior  or  peripheral 
variety  occurs  in  the  anterior  portion  of  the  vertebral  body,  supplied  with 
blood  tlirough  the  intercostal  vessels,  and  lying  immediately  beneath  the 
anterior  common  ligament  of  the  vertebra.  This  type  of  the  disease  is 
practically  limited  to  adults.  (4)  Lastly,  there  are  extremely  rare  forms 
of  the  disease,  which  attack  one  or  other  of  what  one  may  terra  the  vertebral 
appendages,  and  most  commonly  tiie  transverse  processes.  In  each  of 
these  four  varieties  the  exact  pathology  is  very  similar,  but  it  is  best  observed 
as  it  occurs  in  the  centra!  form. 

Chang-es  in  Individual  Vertebra. — It  is  probable  that  a  vertebra 

8 


114  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

is  predisposed  to  tuberculous  disease  by  a  preliminary  change  in  the  main 
nutrient  vessel.^  This  change  is  of  the  nature  of  a  tuberculous  endarteritis 
obliterans  ;  it  is  the  result  of  a  tuberculous  toxaemia,  and  it  affects  these 
vessels  which  supply  vertebrae  most  liable  to  trauma  and  strain  ;  hence  the 
common  localisation  of  the  disease  to  the  lower  dorsal  spine.  The  thicken- 
ing of  the  vessel  wall  interferes  with  the  nutrition  of  the  bone  and  its  marrow, 
and  the  marrow  becomes  altered  from  a  resistant  red  marrow  to  one  of  a 
pale,  myxomatous  and  less  resistant  type.  It  is  in  such  an  altered  tissue 
that  the  original  tubercle  makes  its  appearance.  If  there  has  been  a  pre- 
disposing trauma,  it  acts  by  producing  a  small  ecchymosis  in  the  weak  and 
friable  tissue,  and  the  extravasation  of  blood  is  responsible  for  an  arrest  of 
the  tubercle  bacilli.  The  formation  of  a  tuberculous  follicle  is  the  first  stage 
in  the  actual  pathology.  It  is  situated  in  the  centre  of  the  marrow.  It  is 
composed  of  the  usual  arrangement  of  epithelioid  cells,  lymphocytes,  and 
giant  cells,  and  to  the  naked  eye  it  appears  as  a  tiny  grey  point,  standing 
out  from  the  surrounding  marrow.  The  tubercle  enlarges,  others  appear 
around  it,  and  as  they  eventually  coalesce,  a  considerable  focus  of  disease 
is  formed.  Caseation  appears  in  the  centre,  and  the  original  grey  colour  of 
the  diseased  area  is  now  altered  and  replaced  by  a  variety  of  colour,  a  yellow 
interior,  a  grey  periphery,  and  a  thin  limiting  zone  of  congested  marrow. 

As  the  disease  spreads  throughout  the  cancellous  spaces  it  comes  into 
contact  with  the  bone  lamellae.  These  are  rarefied,  and  if  possible  entirely 
absorbed  before  they  become  surrounded  by  the  diseased  tissue.  Should 
the  lamellae  become  isolated  before  they  are  completely  absorbed,  they 
form  minute  sequestra.  Attention  has  been  drawn  to  the  preliminary 
changes  which  the  marrow  undergoes.  When  the  disease  is  well  established 
the  myxomatous  marrow  in  the  immediate  neighbourhood  of  the  disease 
shows  a  tendency  towards  the  development  of  fibrous  tissue  and  the  limita- 
tion of  the  tuberculous  tissue.  It  is  an  interesting  fact,  and  one  which  has 
never  been  explained,  that  in  tuberculosis  of  the  vertebrae  the  periosteum 
rarely  forms  any  degree  of  new  bone.  It  is  difficult  to  understand  when 
one  remembers  how  typical  is  the  formation  of  new  subperiosteal  bone  in 
other  situations. 

The  entire  architecture  of  the  bone  is  now  altered  ;  the  interior  of  the 
body  has  lost  all  stability,  and  the  weight  and  pressure  are  entirely  borne 
by  the  thin  compact  bone  of  the  periphery.  It  is  like  a  box  with  walls  of 
unstable  cardboard.  Upon  each  vertebra  a  considerable  amount  of  pressure 
is  normally  exerted,  and  such  pressure,  most  marked  in  the  anterior  part 
of  the  column,  is  borne  by  the  thick  bodies  and  the  strong  intervertebral 
discs.  If  the  strength  of  the  body  of  one  or  more  vertebrae  is  undermined 
by  a  central  rarefying  disease,  the  continuation  of  pressure  produces  a 
crumpling  up  and  a  collapse  of  the  body.  The  body  having  collapsed,  and 
the  posterior  part  of  the  spine,  pedicles,  laminae,  and  transverse  processes 
remaining  healthy  and  mi  situ,  the  result  is  the  development  of  an  angulation 
or  kyphosis. 

1   Fraser,  Ediii.  ^r.  J..  1912,  N.S.  ix.  430-441. 


PLATK  XMII 
«,  Till- 


Thk  I'atiiol(k;ical  Vahiktiks  ok  Pott's  Disease  (after  WuUstcin). 


iitriil  viiT'ii'ty  of  I'ott's  ilisease.     b.  The  c])ipliyseal  variety  of  Pott's  disease. 
r,  The  anterior  or  peripheral  variety  of  Pott's  disease. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


115 


The  vertical  pressure  which  is  exerted  upon  the  diseased  vertebra  is 
the  result  of  the  superincumbent  weight  and  of  the  contraction  of  the  irritated 
muscles  which  lie  along  each  side  of  the  spine.  The  natural  tendency  which 
the  disintegrated  vertebra  has  to  produce  a  kyphosis,  places  the  anterior 
muscles  at  a  mechanical  advantage  over  the  posterior.  The  gradual  increase 
in  power  of  the  anterior  muscles  accentuates  the  kyphosis,  and  the  posterior 
muscles  by  becoming  stretched  act  at  a  greater  and  greater  disadvantage. 
With  the  collapse  of  the  body  the  disease  is  more  widely  disseminated,  it 
may  be  extended  among  the  surrounding  soft  parts  to  form  the  origin  of  a 
cold  abscess. 

When   secpestra   occur   they   are   of   the   minute   variety,    intimately 


KlQ.  7.  —  Dors.il  Pott's  disease.  Tliu  roiiiuleil 
kyphosis  inilicates  disease  affecting  tlie  bodies 
of  .several  vertelirse. 


Fill.  S. — Dorsal  Pott's  disea.se.  The  anguhir 
lirojeotion  inilicates  a  disease  affeeting  prob- 
ably a  single  vertebrae. 


mi.ved  with  the  caseating  and  purulent  debris.  Sequestra  of  larger  size  may 
occur,  hilt  they  are  broken  up  and  destroyed  when  the  body  of  the  vertebra 
colla])ses. 

The  amount  and  tiie  character  of  the  kyphosis  depend  upon  two  factors  : 
the  number  of  vertebrae  affected,  and  the  situation  in  wiiich  the  disease 
has  occurred.  Disease  in  a  single  vertebra  ])roduces  a  sharp  kyphoses,  with 
probably  little  general  deformity.  Co-o.xistcnt  disea.se  of  several  vertebra; 
gives  rise  to  a  rounded  gibbosity,  with  considerable  general  deformity. 
The  alterations  in  different  regions  of  the  spine  have  been  demonstrated 
by  -Menard. ^  In  the  cervical  legion  de.stiuction  of  the  vertebral  bodies 
does  not  produce  much  kyphosis,  because  inflexion  is  largely  prevented  by 
interposition  of  the  rof)ts  of  the  pedicles  where  they  come  off  from  the  .sides 
of  the  vertebne.  The  cervical  region,  on  account  of  the  .space  which  normally 
'   Kfudc  pratique  sur  Ic  mill  ilv  I'ult,   I'aris,  Slasson  &  Cic,  1900. 

8  a 


116 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


exists  between  the  posterior  arches,  permits  of  a  considerable  degree  of 
hyperextension,  and  when  inflexion  occurs  it  is  corrected  by  hyperextension. 
The  result  is  a  slight  kyphosis  and  some  degree  of  shortening  in  the  spinal 
column. 

In  the  dorsal  region  of  the  spine,  destruction  of  a  single  body  produces 
a  distinct  kyphosis,  and  the  deformity  is  more  marked  as  other  vertebrae 
are  affected.  This  striking  difference  depends  upon  the  anatomical  fact 
that  in  the  dorsal  spine  the  pedicles  do  not  come  oS  from  the  side  of  the  body, 
but  from  the  posterior  surface,  therefore  they  cannot  by  interlocking  prevent 
a  spinal  inflexion.  The  deformity  cannot  be  neutralised  by  hyperextension 
as  in  the  cervical  region,  because  the  laminae  and  the  spine  are  normally  so 
close  together  that  very  little  extension  is  possible. 

When  the  lumbar  spine  is  diseased,  the  results  resemble  those  found  in 
the  cervical  spine.  On  account  of  the  thick  intervertebral  discs  and  the  large 
interlaminary  and  interspinous  spaces,  there  is  considerable  power  of  hyper- 
extension. Collapse  of  the  lumbar  body  is  counterbalanced  by  a  corre- 
sponding degree  of  hyperextension,  and  the  result  is  a  slight  kyphosis  and 
some  amount  of  shortening.  Sometimes,  although  the  diseased  vertebra 
has  collapsed,  the  body  above  does  not  come  into  contact  with  the  body 
below.  Until  there  is  actual  contact,  a  supposed  cure  is  more  apparent  than 
real. 

In  addition  to  the  changes  in  the  bodies  of  the  vertebrae,  there  are 
changes  in  the  arches.  The  posterior  arch  of  the  diseased  body  is  partly 
dislocated  backwards,  giving  origin  to  the  early  spinal  prominence.  The 
posterior  segment  is  wasted  and  atrophied,  and  sometimes  it  is  firmly 
ankylosed  to  segments  above  and  below  by  the 
C[uantity  of  new  bone  thrown  out  from  its  surface 
and  attachments. 

Chang'es  in  Vertebral  Column  as  a  Whole. — 
The  essential  deformity  of  Pott's  disease  is  a  kyphosis, 
but  there  are  compensatory  changes  above  and  below. 
These  compensations  are  in  the  shape  of  curves,  to 
maintain  the  figure  in  a  correct  attitude. 

In  cervical  disease  the  axis  of  the  skull  becomes 
altered,  and  there  is  a  compensatory  curve  in  the 
dorsal  spine.  When  the  disease  attacks  the  dorsal 
spine,  its  most  favourite  situation,  there  are  com- 
pensatory lordotic  curves  in  the  cervical  and  lumbar 
regions.  If  the  angulation  is  in  the  lower  part  of  the 
lumbar  region,  any  kyphosis  which  may  occur  is 
largely  compensated  for  by  hyperextension  of  the 
hip-joints. 

Lateral  Deviation  of  the  Spine. — Occasionally 

one  finds  that  in  addition  to  a  kyphotic  deformity 

there   is   also   a   lateral    one,   and   the    complication 

the    erroneous    diagnosis    of    simple    scoliosis.      A 


-Scoliosis  in  Pott's 
disease. 


sometimes    leads    to 


TUBERCULOUS  DISEASE  OF  THE  SPINE  117 

lateral  deviation  occurs  in  Pott's  disease  for  two  reasons.  The  first  is  that 
when  in  the  collapse  of  the  spine,  owing  to  the  destruction  of  a  vertebra, 
the  upper  segment  does  not  fall  true  upon  the  lower  one,  a  sharp  and  almost 
angular  scoliosis  results.  The  second  possible  cause  is  the  irregular  course 
of  the  disease.  If  only  one-half  of  the  vertebral  body  is  destroyed,  and 
the  disease  spreads  to  the  vertebral  half  immediately  below,  a  lateral 
deviation  will  result.  It  is  usually  uniform,  and,  apart  from  the  muscular 
rigidity,  it  closely  resembles  at  first  sight  a  simple  scoliosis. 

Chang-es  in  the  Spinal  Cord  and  its  Membranes. — From  the  close 
proximity  of  the  spinal  cord  to  the  disease,  it  is  but  natural  to  expect  that 
when  a  kyphosis  occurs,  pressure  will  be  exerted  upon  the  cord,  pressure 
of  such  a  degree  as  to  give  rise  to  symptoms.  In  reality  such  a  sequel  is  the 
exception  rather  thau  the  rule.  The  power  of  accommodation  is  so  great 
that  even  a  very  extensive  deformity  will  produce  no  nervous  tissue 
change. 

In  a  certain  proportion  of  cases  pressure  upon  the  cord  does  occur, 
producing  what  has  been  called  "  compression  paraplegia,"  and  the  changes 
which  produce  it  may  originate  (1)  in  the  bones  of  the  spinal  column  ;  (2) 
in  the  spinal  membranes  ;    (3)  in  the  spinal  cord  itself. 

( 1 )  Bone  Causes. — It  is  very  exceptional  to  find  that  the  bending  of  the 
spinal  column  is  of  such  a  nature  as  to  compress  the  spinal  cord.  It  angles, 
but  rarely  compresses.  A  partial  dislocation  is  a  more  common  source  of 
bone  pressure.  When  the  diseased  vertebra  collapses,  the  upper  segment  is 
displaced  somewhat  backwards,  and  its  posterior  edge  comes  into  contact 
with  the  enclosed  nerve  tissue.  Cases  have  been  recorded  in  which  a  seques- 
trum has  gradually  been  extruded  from  the  diseased  area,  and  has  exerted 
pressure  upon  the  nerve  tissue.  The  commonest  manner  in  which  the 
diseased  bone  causes  compression  is  an  actual  extension  of  the  disease, 
either  as  tuberculous  granulation  tissue  or  as  a  cold  abscess.  The  disease 
within  the  body  of  the  vertebra  has  a  tendency  to  extend  to  the  exterior 
through  the  posterior  surface,  and  more  especially  along  the  vessels 
entering  the  bones  through  the  large  nutrient  foramina.  At  first  the 
extension  is  limited  by  the  posterior  ligament.  When  this  becomes 
perforated  the  epidural  space  is  invaded,  and  pressure  is  at  once  exerted 
upon  the  cord. 

(2)  Membrane  Causes. — By  the  extension  of  the  disease  a  tuberculous 
perimeningitis  is  produced  ;  this  is  followed  by  a  pachymeningitis,  and 
later  even  by  a  leptomeningitis.  As  the  membranes  become  diseased 
they  become  thickened,  and  then  blood  and  lymph  vessels  are  obliterated. 
In  this  way  the  cord  undergoes  a  slow  and  gradual  compression  witli 
resulting  changes  in  its  nerve  elements. 

(3)  Spinal  Cord  Cau.^es. — The  nervous  tissue  of  the  cord  is  })rttctically 
never  actually  infected  with  tuberculosis ;  the  changes  which  it  undergoes  are 
secondary.  Its  actual  circumference  may  be  Hattened  and  constricted  by 
pressure.  Owing  to  the  obliteration  of  the  blood  and  lymph  vessels  in  the 
spinal  nnMnhranrs,  there  is  a  local  o'denin  of  the  cord,  and  the  avlcina  may 


118 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


become  a  subacute  myelitis  with  softening.  If  myelitis  occurs,  there  will 
be  a  destruction  of  a  certain  number  of  the  nerve  filaments,  a  proliferation 
of  the  neuroglia  and  sclerosis,  followed  at  a  later  date  by  ascending  and 
descending  nerve  degeneration.  Fortunately  it  is  the  exception  for  the 
changes  to  be  so  severe  as  to  produce  myelitis.  The  nerve  roots  undergo 
changes  very  similar  in  every  respect  to  those  which  occur  in  the  spinal  cord. 
Chang-es  in  the  Heart  and  Great  Vessels. — The  heart  is  altered  in 

position  and  in  size.  It  is 
altered  in  position  as  a  result 
of  the  kyphosis,  and  naturally 
the  most  marked  alterations 
occur  when  the  deformity  is 
situated  in  the  upper  and 
mid -dorsal  regions.  The 
change  in  position  is  of  such 
a  nature  that  the  base  of 
the  heart  is  displaced  down- 
wards, while  the  apex  ap- 
pears to  be  tilted  upwards. 
The  heart  appears  to  be 
rotated  upon  a  transverse 
horizontal  axis.  The  upward 
displacement  of  the  apex  is 
more  apparent  than  real,  as 
it  is  exaggerated  by  the 
alteration  in  the  position  of 
the  ribs. 

The  size  of  the  heart  is 
changed  by  the  hyjaertrophy 
which  it  consistently  under- 
goes. Attention  is  drawn 
later  to  the  kinking  of  the 
aorta.  As  a  result  of  the 
kinking,  the  work  of  the 
heart  is  increased,  and  there 
is  an  hypertrophy,  and  later 
a  dilatation  of  the  left  ven- 
tricle.    The  other  chambers  of  the  heart  undergo  similar  changes. 

The  aorta  and  the  vena  cava  are  altered  in  direction  and  in  size.  The 
aorta  is  liable  to  become  kinked  in  two  positions,  about  the  centre  of  the 
transverse  portion  and  again  opposite  the  kyphosis.  The  vessel  may  be 
kinked  antero-posteriorly  or  deviated  laterally,  sometimes  a  combination  of 
both.  The  antero-posterior  deformity  is  the  more  serious,  there  is  a  val\Tilar 
formation  of  he  anterior  wall  which  offers  very  considerable  obstruction 
to  the  blood  flow.  The  changes  in  the  vena  cava  are  very  similar  to  those 
found  in  the  aorta  ;   on  account  of  the  thinness  of  its  wall  this  vessel  accom- 


Fi( 


10. — The    Uinkiug   of  the   great  vessels   secondary  to 
tuberculous  disease  of  the  vertebrte.     (WuUsteiu.) 


TUBEECULOUS  DISEASE  OF  THE  SPINE 


119 


modates  itself  more  easily  to  the  alteration  in  position  than  is  the  case  in 
the  aorta. 

These  vascular  changes  are  responsible  for  the  coldness  and  malnutri- 
tion of  the  lower  extremities  which  one  so  constantly  finds  in  Pott's  disease. 

Chang-es  in  the  Thorax, — These  are  so  excellently  summarised  by 
Tubby  that  one  cannot  do  better  than  cpote  his  words  :  ^ 

"  In  the  chest  three  varieties  of  deformity  are  seen  :  A.  li  the  curve  is 
high  up  in  the  dorsal  region,  the  true  ribs  are  held  at  an  angle  greater  than  the 
normal,  the  sternum  is  displaced  downwards,  and  the  antero-posterior  diameter 


Mid-ilorsal. 


High  ilor-sal. 


Dorso-lumb.ar. 


Fig.  11. 


-A  cUagramatic  representation  of  the  thoracic  deformity  in  mid  dorsal  kyphosis, 
high  dorsal  kyphosis,  and  dorso-liimliar  kyphosis.     (Menard.) 


of  the  thora.x  is  diminished.  In  fact  the  chest  is  in  an  c.\])iratorv  position.  B. 
If  the  disease  is  low  down  in  the  dorsal  region,  the  ribs  and  sternum  are  raised, 
the  antero-posterior  diameter  of  the  chest  is  lengthened,  and  the  che.st  is  barrel- 
shaped,  and  is  in  a  position  of  iiis]iiration.  Therefore  the  hreatliing  is  dia- 
phragmatic, and  the  patient  is  short  of  breath.  C.  Wiien  the  lumbar  region  is 
affected  the  whole  thorax  sinks  downwards  and  forwards,  the  lower  ribs  over- 
ride the  pelvis,  the  ensiform  cartilage  approximates  to  the  symphysis  pubis, 
and  tlie  abdominal  wall  is  thrown  into  folds.  " 

Changes  in  the  Pelvis.— Disease  of  the  cervical  or  upper  dorsal  spine 
is  unaccompanied  by  any  change  in  the  architecture  of  the  pelvis.  When 
the  disease  occurs  in  the  dorso-lunibar  region,  producing  there  some  degree 
of  kyphosis,  there  are  changes  in  the  pelvis  compensatory  to  the  angulation. 
The  sacium  is  rotated  upon  a  central,  transverse,  horizontal  axis,  its  upper 


'  'ruld)y,  Urfuniiiticn,  including  Diseases  of  the  Hones  and  Joints,  vol.  ii.  p.  !I5. 


120  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

half  is  displaced  backwards,  while  the  lower  half  is  carried  forwards.  The 
iliac  crests  become  splayed  outwards,  and  the  inlet  of  the  pelvis  is  increased 
in  its  antero-posterior  and  transverse  diameters.  The  outlet  of  the  pelvis 
is  diminished  in  size  by  the  tilting  forwards  of  the  lower  part  of  the  sacrum, 
and  an  approximation  of  the  tuberosities.  The  ischia  are  approximated 
because  the  displaced  sacrum  acts  as  a  wedge,  forcing  apart  the  upper  parts 
of  the  pelvis,  while  the  lower  parts  in  compensation  are  approximated. 
The  pelvis  is  said  to  become  funnel-shaped  in  outline.  "When  the  disease 
affects  the  lumbosacral  region,  there  is  no  tilting  of  the  sacrum.  The  whole 
bone  is  displaced  downwards  and  backwards,  and  therefore  there  is  not  the 
tendency  to  narro^ving  of  the  pelvic  diameters  which  one  finds  in  disease 
higher  up. 

Abscess  Formation. — There  is  no  more  common  complication  met 
with  in  tuberculosis  of  the  spine  than  that  of  abscess  formation,  and  while 
it  is  discussed  later  in  its  clinical  aspect,  it  is  essential  to  study  it  here 
from  its  pathological  side.  It  is  calculated  that  20  per  cent  of  cases 
pass  on  to  abscess  formation  (Townsend).^ 

The  Origin  of  the  Abscess. — The  caseation  and  rarefaction  which 
goes  on  within  the  bone  is  really  a  modified  cold  abscess  formation,  but  as 
long  as  the  disease  is  localised  to  the  bone  the  term  abscess  cannot  be 
theoretically  applied.  In  process  of  time  the  disease  extends  to  the  surface 
and  perforates  the  limiting  zone,  or  the  osseous  shell  collapses  and  the 
caseous  matter  is  disseminated  into  the  soft  parts  around.  To  either  of 
these  possibilities  the  cold  abscess  owes  its  origin.  There  is  a  third  possi- 
bility which  one  occasionally  finds  illustrated,  the  cold  abscess  may  begin 
as  an  extension  of  tuberculous  disease  from  the  interior  of  the  vertebra, 
along  the  course  of  one  of  the  larger  nutrient  vessels,  and  more  especially 
along  the  sheath  of  the  large  artery  which  enters  the  body  from  its  posterior 
surface.  The  abscess  which  is  really  a  progressive  caseation  in  the  soft 
tissues  and  intermuscular  septa  may  remain  in  the  proximity  of  the  original 
osseous  lesion,  or  it  may  become  wandering  or  migratory. 

The  Course  of  the  Abscess. — The  course  varies  in  the  different 
regions  of  the  spine — cervical,  dorsal,  or  lumbar. 

A.  Abscesses  originating  in  the  Cervical  Spine. — To  understand  the 
possible  directions  of  a  cervical  abscess  it  is-essential  to  describe  first  the 
relation  of  the  deep  cervical  fascia,  because  the  situations  of  the  abscesses 
are  guided  almost  entirely  by  the  attachments  of  this  structure. 

The  deep  cervical  Fascia. — From  the  spine  tips  of  the  cervical  vertebras 
the  ligamentum  nuchae  passes  backwards  in  the  middle  line  of  the 
neck.  From  the  posterior  edge  of  the  ligamentum  nuchae,  the  superficial 
layer  of  the  deep  cervical  fascia  passes  forwards  to  reach  the  posterior 
margin  of  the  trapezius  muscle.  Here  the  fascia  divides  into  two  lamellaj, 
which  enclose  the  trapezius  and  reunite  at  its  anterior  border.  From  this 
point  the  fascia  sweeps  forwards  to  form  the  roof  of  the  posterior  triangle, 
and  then  splits  to  enclose  the  sterno-mastoid  muscle.     It  again  reunites  at 

1  Townsend,  Trans.  Amer.  Orth.  Assoc,  vol.  iv.  p.  164. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


121 


the  anterior  margin  of  the  muscle,  to  become  continuous  with  the  fascia 
of  the  opposite  side.  The  fascia  forms  a  complete  collar  around  the  neck, 
splitting  to  enclose  the  trapezius  and  sterno-mastoid  muscles  of  each  side. 
This  superficial  collar  has  most  important  vertical  attachments.  Above, 
it  can  be  traced  to  the  superior  curved  line  of  the  occiput,  the  mastoid 
process,  over  the  parotid  gland,  to  the  zygoma,  and  along  the  inferior  aspect 
of  the  lower  jaw  from  the  angle  to  the  symphisis.  Below,  the  fascia  is 
attached  to  the  spine  of  the  scapula,  the  acromion  process,  the  clavicle,  and 
the  manubrium  sterni ;  as  transversely  it  splits  twice  to  enclose  structures, 
so  vertically  it  splits  twice.  Above,  between  the  lower  jaw  and  the  hyoid 
bone,  it  embraces  the  submaxillary  gland  ;  below,  two  inches  above  the 
suprasternal  notch,  it  separates  into  two  lamellae,  enclosing  a  triangular 
interval  (Burns's  space).  This  space  con- 
tains the  sternal  head  of  the  sterno- 
mastoid,  one  or  two  lymphatic  glands 
and  vessels,  and  portions  of  the  anterior 
jugular  veins.  This  layer  of  fascia  is 
pierced  by  the  external  jugular  vein  just 
above  the  clavicle.  From  the  deep  sur- 
face of  the  circular  superficial  layer,  two 
deep  processes  pass  across  the  neck  :  the  ^ 
pretracheal  and  the  prevertebral  layers. 

The  pretracheal  layer  springs  from 
the  lamella  lining,  the  deep  surface  of 
the  sterno-mastoid  muscle.  It  passes 
across  the  neck  in  front  of  the  trachea 
and  ocsophagiis,  enclosing  in  its  course 
the  thyroid  gland.  It  is  attached  to  the 
lamella  upon  the  deep  surface  of  the 
opposite  sterno-mastoid  muscle.  Verti- 
cally it  is  attached  above  to  the  hyoid 
bone,  while  below  it  passes  into  the 
mediastinum. 

The  prevertebral  layer  extends  in- 
wards from  the  deep  surface  of  the  cervical  fascia  as  it  passes  across 
the  roof  of  the  posterior  triangle.  It  covers  the  prevertebral  muscles  and 
the  spinal  column.  Above  it  is  attached  to  the  base  of  the  skull,  below 
to  the  first  rib,  where  the  inner  portion  becomes  continuous  with  the 
posterior  mediastinum.  The  outer  portion  forms  the  sheath  of  the  sub- 
clavian ves.sels,  and  continues  downwards  with  them  into  the  axilla.  The 
carotid  sheath  is  a  special  investment  formed  by  the  pretracheal  and  pre- 
vertebral fasciae.  The  neck  is  therefore  subdivided  by  these  processes 
into  three  compartments  :  («)  The  muscular,  between  the  superficial  and 
the  |)retrachcal  layers,  containing  the  depressor  nuiscles  of  the  hyoid  bone  ; 
(6)  the  visceral,  between  the  pretracheal  and  prevertebral  layers,  containing 
the  hirynx,  pharynx,  oesophagus,  trachea,  aiul  thyioid  gland  ;    and  (c)  the 


Vh,.  12. — The  arraiigenient  of  the  cervical 
fascia.     The  fascia  is  coloureil  red. 


122  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

vertebral  compartment,  behind  the  prevertebral  layer,  containing  the  pre- 
vertebral muscles,  the  cervical  sympathetic,  and  the  vertebral  column. 

AVhen  the  cold  abscess  is  secondary  to  disease  in  the  cervical  spine,  the 
pus  will  follow  tracks  which  largely  depend  upon  the  attachments  of  the 
cervical  fascia.     The  possibilities  are  as  follows  : 

(1)  The  pus  may  accumulate  behind  the  prevertebral  fascia,  between  it 
and  the  anterior  surface  of  the  cervical  vertebrae.  It  bulges  the  fascia  for- 
wards, and  it  is  designated  a  retro-pharyngeal  abscess ;  laterally  it  ajipears 
at  the  posterior  edge  oj  the  sierno-mastoid  muscles. 

(2)  The  pus  may  penetrate  the  prevertebral  fascia,  in  which  case,  if 
situated  high  up,  it  enters  the  mouth,  if  low  down  it  enters  the  visceral 
compartment  of  the  neck,  infiltrating  around  the  gullet  and  the  air  passages. 
Pus  in  this  region  has  no  special  tendency  to  point  in  the  neck  ;  it  more 
frequently  passes  downwards  into  the  mediastinum  or  into  the  axilla.  It 
may  find  its  way  into  the  interior  of  the  oesophagus. 

(3)  The  pus  may  track  along  the  lateral  surface  of  the  cervical  vertebrae, 
between  the  spine  and  the  ligamentum  nuchse  upon  the  inner  side,  and  the 
posterior  cervical  muscles  upon  the  outer  side.  It  penetrates  the  deep 
cervical  fascia,  and  appears  at  one  or  other  side  of  the  vertebral  spines. 

B.  Abscesses  originating  in  the  Dorsal  Spine. — Dorsal  abscesses  are 
generally  small,  and  they  usually  remain  in  close  contact  with  the  spine. 
Owing  to  the  depth  of  the  dorsal  spine  from  the  surface,  the  pus  is  frequently 
retained,  and  it  may  make  its  way  within  the  spinal  canal,  and  give  rise  to 
a  paraplegia.  The  possible  course  of  the  abscess  is  guided  by  the  anatomical 
relations  of  the  lateral  aspects  of  the  dorsal  spine.  With  the  exception  of 
the  first  rib  and  of  the  last  three  ribs,  the  head  of  each  rib  articulates  with  the 
bodies  of  two  vertebrae  and  the  intervening  intervertebral  substance.  The 
heads  of  the  first,  tenth,  eleventh,  and  twelfth  ribs  are  implanted  directly 
upon  the  bodies  of  the  corresponding  vertebrae.  Each  rib  is  attached  to 
the  side  of  the  vertebrae  by  several  ligaments,  the  most  important  of  which 
are  the  anterior  capitular  or  stellate  ligament  and  the  superior  costo-trans- 
verse  ligament.  Between  the  inner  edge  of  the  superior  costo-transverse 
ligament  and  the  lower  and  upper  edges  of  adjacent  stellate  ligaments  there 
is  a  weak  point  in  the  anterolateral  aspect  of  the  spinal  column. 

The  interval  between  the  posterior  extremities  of  the  ribs  is  filled  up 
by  the  internal  and  external  intercostal  muscles  and  the  posterior  inter- 
costal membrane.  The  external  intercostal  muscles  extend  inwards  as  far 
as  the  tubercles  of  the  ribs,  the  internal  intercostals  end  at  the  angles  of  the 
ribs,  the  further  interval  being  filled  up  by  the  posterior  intercostal  mem- 
brane. The  inner  edge  of  the  posterior  intercostal  membrane  is  attached 
to  the  outer  edge  of  the  superior  costo-transverse  ligament.  The  bodies 
of  the  vertebrae  are  bound  together  in  front  by  the  anterior  common  ligament. 
The  anatomical  relation  of  the  posterior  primary  divisions  of  the  dorsal 
nerves  must  be  briefly  mentioned.  They  make  their  appearance  in  the 
intervals  between  the  transverse  processes,  and  immediately  divide  into 
external   and   internal    branches.     The   external   branches   pass    outwards 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


123 


under  cover  of  the  middle  column  of  the  erector  spinse  muscle,  and  of  their 
number  only  the  lower  five  become  cutaneous  about  the  position  of  the  rib 
angles. 

The  internal  branches  are  distributed  in  a  fashion  almost  the  reverse 
of  the  external ;  the  lower  five  branches  are  very  small,  and  they  do  not 
become  superficial  ;  the  upper  seven  pass  inwards  between  the  multifidus 
spinae  and  the  semispinahs,  and  after  piercing  the  splenius,  rhomboideus, 
and  trapezius  muscles  they  become  superficial.  As  will  be  shown  later, 
special  interest  attaches  to  the  arrangement  of  the  posterior  divisions  of  the 
dorsal  nerves. 

The  aortic  intercostal  arteries  have  important  bearings  upon  abscess 


Fig.  13. — The  ilistribution  of  the  posterioi-  [iriniaiy  ilivision  of  tliu  dors.il  iicrvi-s.  illu.-tr.iUil  liy 
a  section  at  the  level  of  the  seventh  dorsal  vertebra'.  Note  the  superlicial  clistrilmtioii  ol  the 
inner  branch  of  the  nerve. 

situation.  One  is  given  oil  to  each  of  the  nine  lower  intercostal  spaces 
upon  both  sides  of  the  body.  In  both  cases  they  pass  outwards  over  the 
body  of  the  vertebrae,  and  as  they  leave  the  vertebral  column  to  enter  the 
intercostal  spaces,  each  of  the  vessels  gives  oflt  a  large  dorsal  branch,  which 
passes  backwards  in  the  interval  between  the  transverse  processes,  and  is 
distributed  to  the  muscles  and  skin  of  the  back.  From  this  branch  a  special 
twig  is  supplied  through  the  intervertebral  foramen  to  the  spinal  cord  and 
its  membranes. 

In  each  space  the  intercostal  artery  proceeds  outwards,  first  lying  be- 
tween the  pleura  and  the  posterior  intercostal  membrane,  and  afterwards 
between  the  muscular  layers  of  the  internal  and  external  intercostals. 

These  anntoniical  points  have  been  given  in  detail  becau.se  each  of  them 


124 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


has  important  bearings  upon  the  position  which  a  dorsal  abscess  may  take. 
The  various  positions  which  a  dorsal  abscess  may  assume  are  as  follows  : 

(1)  It  may  be  retained  in  front  of  the  spine,  behind  the  periosteum  or 
the  anterior  common  ligament  (prevertebral  abscess). 

(2)  It  may  extend  through  the  anterior  common  ligament,  and  invade 
the  space  of  the  posterior  mediastinum. 

(3)  It  may  pass  more  laterally  and  come  to  lie  beneath  the  pleura, 
sometimes  penetrating  the  jileura  and  producing  a  tuberculous  empyema. 

(4)  It  may  gravitate  downwards  beneath  the  ligamentum  arcuatum 
internum,  and  assume  the  positions  compatible  with  a  lumbar  abscess  (see 
below). 

(5)  It  may  make  its  way  backwards  between  the  transverse  processes, 
through  the  weak,  triangular  interval,  bounded  by  the  superior  costo-trans- 
verse  and  the  stellate  ligaments.  AVhen  it  gets  into  this  situation  its  further 
course  depends  upon  whether  it  follows  the  course  of  the  blood-vessels  or 
the  j)Oster;or  primary  division  of  the  nerves. 

(6)  Following  the  track  of  the  blood-vessels,  the  abscess  may  extend 
along  the  dorsal  branch  of  the  intercostal  artery,  or  it  may  pass  outwards, 
accompanying  the  main  intercostal  vessel,  and  appearing  on  the  surface, 
sometimes  where  the  lateral  branch  is  distributed  and  sometimes  at  the 
anterior  extremity  of  the  intercostal  space. 

(7)  When  the  nerves  act  as  guides,  the  abscesses  may  follow  either  the 
internal  or  the  external  branches  of  the  posterior  primary  divisions.     If  the 

external  branches  are  followed,  the  ab- 
scess appears  at  some  distance  from  the 
middle  line,  and  as  only  the  five  lower 
nerves  of  this  group  become  cutaneous, 
abscesses  are  likely  to  appear  in  the 
corresponding  positions.  When  the 
abscess  tracks  along  the  internal  branch, 
it  appears  close  to  the  middle  line,  and 
usually  in  the  upper  seven  spaces,  as  the 
lower  five  nerves  do  not  become  super- 
ficial. 

(8)  An    abscess   from   the   first  four 

dorsal    vertebrae   may   follow   the   same 

course  as  a  cervical  abscess. 

I  ^^w.^  i\lllu\Uuil]|lllP  t'-  Abscesses  originating  in  the  Lumbar 

'  ^-JJy    ,lillliU\lllr  Spine.  —  The      lumbar      vertebrae     are 

peculiarly  related  to  the  attachments  of 
the  psoas,  iliac,  and  lumbar  fasciae,  and 

FlG.14.-Therelationsofthefasci^inregar,l   ^S  the  positions  of  the  VarioUS  absceSSeS 

to  the  iieveiopraeut  of  abscesses  secondary  are  determined  by  these  structures,  it  is 

to  Pott's  disease  of  the  lumbar  spine.  u   •   ii      1      i  -t      xr,  rni, 

'^  necessary  brieny  to  describe  them.     Ihe 

fascia   covering   the    psoas  and  iliacus  is  one  continuous  sheet.     Above 
it  is   thin   and   comparatively  narrow,   covering   over    the   psoas    muscle, 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


125 


below  it  expands  to  cover  the  psoas  and  iliacus  muscles,  and  it 
becomes  much  denser  and  stronger.  The  attachments  of  the  fascia 
are  all  important.  Superiorly  it  forms  the  thickened  band  of  the  liga- 
mentum  arcuatum  internum,  arching  over  the  psoas  muscle,  and  attached 
by  one  extremity  to  the  tip  of  the  transverse  process  of  the  first  lumbar 
vertebra,  and  by  the  other  to  the  body  of  the  second  lumbar  vertebra, 
and  the  tendonous  part  of  the  corresponding  crus  of  the  diaphragm. 
Externally  its  attachment  differs  above  and  below  the  crest  of  the  ilium. 
Above  it  is  attached,  externally  to  the  fascia  covering  the  quadratus  lum- 
borum,  the  anterior  lamella  of  the  lumbar  fascia.  Below,  when  it  becomes 
the  fascia  iliaca,  it  is  firmly  fixed  to  the  crest  of  the  ilium.  Internally 
its  attachment  also  varies.  In  its  upper  part  it  is  fixed  to  the  spine  by  a 
series  of  fibrous  arches  which  bridge  over  the  lumbar  arteries  ;   lower  down 


Fig.  15. — The  arrangement  of  the  lumbar  fascia.     The  various  ilivisioiis  of  the  fascia 

are  coloured  red. 


it  sweeps  over  the  psoas,  and  is  attached  to  the  brim  of  the  true  pelvis. 
Inferiorly,  to  the  outer  side  of  the  iliac  vessels,  the  fascia  becomes  adherent 
to  the  fascia  transversalis,  when  both  are  attached  to  Poupart's  ligament. 
Behind  this  outer  division  of  the  fascia  the  ilio-psoas,  the  anterior  crural 
nerve,  and  the  external  cutaneous  nerve  are  carried  downwards  into  the 
thigh. 

The  inner  portion  of  the  lower  end  of  the  fascia  is  prolonged  downwards 
into  the  thigh,  behind  the  femoral  vessels,  to  form  the  posterior  wail  of  the 
femoral  sheath. 

The  lumbar  fascia  is  really  the  posterior  aponeurosis  of  the  transversalis 
muscle.  As  the  fascia  approaches  the  spine  it  splits  into  three  layers  or  lamellte: 
the  posterior  lamella  is  attached  to  the  spine  tips  of  the  vertebrse,  the  inter- 
mediate lamella  to  the  tips  and  adjacent  sides  of  the  transverse  processes, 
the  anterior  to  the  bodies  of  the  vertebraj  at  the  roots  of  the  transverse 
processes.  Two  compartments  are  thus  formed  :  in  the  anterior  the  quad- 
ratus luinboruni  lies,  the  posterior  is  occupied  by  the  erector  sjiinn?.     The 


126 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


fascia  of  the  anterior  lamella  is  continuous  with  the  outer  side  of  the  psoas 
fascia. 

The  lumbar  arteries  are  arranged  on  much  the  same  plan  as  the 
intercostal  vessels.  They  proceed  outwards  upon  the  bodies  of  the  lumbar 
vertebrae,  and  disappear  under  cover  of  the  psoas  muscle.  In  the  intervals 
between  the  transverse  processes  they  divide  into  a  dorsal  and  an  abdominal 
branch.     The  dorsal  branch  turns  backwards,  and  after  giving  off  its  spinal 

twig  to  the  spinal  cord,  pierces  the  posterior 
muscles,  and  ends  in  the  integuments  of  the 
back. 

The  posterior  divisions  of  the  lumbar  nerves 
are  very  similar  in  arrangement  to  those 
described  in  the  dorsal  region.  The  internal 
branches  are  of  small  size,  and  their  distri- 
bution is  purely  muscular.  Of  the  external 
branches  the  upper  three  are  of  large  size, 
and  they  become  cutaneous  by  piercing  the 
superficial  lamella  of  the  lumbar  fascia. 

Each  of  the  above  anatomical  details  has 
important  bearings  upon  the  abscess  course. 

(1)  The  disease  originating  in  the  front  of 
the  body  of  the  vertebra  may  pass  directly 
forwards,  and  failing  to  enter  the  sheath  of  the 
psoas,  it  passes  behind  the  aorta,  and  extends 
downwards  along  the  great  vessels.  It  may 
extend  by  the  external  iliac  into  the  thigh, 
or  it  may  follow  the  internal  iliac  into  the 
pelvis,  and  open  by  the  side  of  the  rectum  or 
through  the  great  sacro-sciatic  foramen. 

(2)  The  disease  may  enter  the  sheath  of 
the  psoas  muscle,  and  gravitate  downwards 
along  it  until  it  appears  beneath  Poupart's 
ligament,  at  either  the  inner  or  the  outer  side 
of  the  femoral  vessels. 

Menard  has  noticed  this  type  of  abscess  extend  in  the  thigh  along  the 
course  of  the  internal  circumflex  vessels,  and  point  behind  the  great  trochanter. 

(3)  The  abscess  may  enter  the  sheath  of  the  psoas  muscle,  but  in  the 
lower  part  of  its  course  it  extends  outwards  beneath  the  fascia  iliaca,  to 
appear  as  an  iliac  abscess  internal  to  the  anterior  superior  spine. 

(4)  It  may  extend  laterally  into  the  sheath  of  the  quadratus  lumborum, 
and  piercing  the  lamellae  of  the  lumbar  fascia,  it  becomes  superficial  above 
the  crest  of  the  ilium  at  Petit's  triangle. 

(5)  The  abscess  ma}'  enter  the  fascial  layers,  further  from  the  middle 
line  than  the  quadratus  lumborum,  in  which  case  it  may  extend  forwards 
between  the  muscles  as  far  as  the  anterior  abdominal  wall. 

(6)  The  course  of  the  abscess  may  be  guided  by  the  dorsal  branches  of 


Fig.  16. — Large  psoas  abscess 
originating  iu  tuberculous 
disease  of  tlie  lumbar  spine. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  127 

the  lumbar  arteries,  and  the  fluctuation  appears  close  to  the  spine  and  often 
below  the  last  rib. 

(7)  Sometimes  the  disease  extends  along  the  nerve  sheaths,  and  com- 
monly along  the  three  upper  of  the  outer  divisions  of  the  posterior  primary 
nerves,  the  abscess  ])ointing  some  distance  from  the  middle  line. 

The  Natural  Method  of  Cure. — Natural  cure  is  most  quickly  brought 
about  when  the  osseous  surfaces  come  into  contact.  The  period  required 
is  more  prolonged  when  the  diseased  body  remains  intact  than  when  it 
collapses,  and  in  this  respect  the  k}'phosis  has  a  certain  salutary  influence. 

Before  repairs  can  occur  the  tuberculous  debris  must  be  absorbed,  or 
at  least  localised  by  surrounding  fibrosis.  The  diseased  area  is  replaced  by 
fibrous  tissue,  and  this  at  a  later  period  by  contraction  may  account  for  an 
apparent  increase  in  the  degree  of  deformitj^.  The  fibrous  tissue  is  after- 
wards ossified,  and  until  ossification  is  complete  a  cure  cannot  be  guaranteed. 
The  fibrosis  and  ossification  is  most  prominent  in  relation  to  the  body  of 
the  vertebra  where  the  disease  primarily  occurred.  Around  the  periphery 
of  the  posterior  arch  new  bone  formation  may  occur,  binding  the  pedicles 
and  occasionally  the  laminaj  together.  These  evidences  of  repair  are  never 
met  with  inside  the  neural  canal. 

The  period  of  time  required  for  complete  fixation  and  cure  varies  in 
different  regions  of  the  spine.  It  is  least  in  the  lumbar  spine.  Under  treat- 
ment fibrosis  occurs  during  the  end  of  the  first  year,  and  ossification  is  well 
marked  at  the  end  of  the  second.  In  the  upper  part  of  the  cervical  region 
the  periods  are  longer,  averaging  two  years  and  three  years  for  fibrosis  and 
ossification.  The  period  is  certainly  longest  in  the  dorsal  spine.  Fibrosis 
appears  only  in  the  end  of  the  third  year,  and  certainly  the  fifth  year  will 
have  been  completed  before  a  proper  ossification  is  recognisable.  These 
facts  are  mentioned  later  in  regard  to  treatment. 

Spondyl  Arthritis. — In  the  occipito-atloid  and  the  atlo-axoid  articu- 
lation there  are  numerous  synovial  articulations  and  the  pathology  of 
tuberculous  disease  in  these  regions  is  peculiar.  The  disease  begins  as  a 
synovial  tuberculosis,  usually  in  the  atlo-axoid  joints,  subsequently  it 
spreads  beyond  the  membranes,  and  becomes  an  osseous  tuberculosis. 

Tuberculous  Disease  origrinating*  in  a  Portion  of  a  Vertebra 
other  than  the  Body. — Occasionally  one  sees  tuberculous  disease  attack- 
ing the  transverse  process  or  the  vertebral  spine,  but  such  occurrences  are 
exceedingly  rare.  Still  more  uncommon  is  it  to  find  tuberculous  disease 
originating  in  the  costo-vertebral  articulation  or  in  the  joints  of  the  articular 
processes. 

Symptoms  and  Physical  Signs 

Symptoms.  In  eni|uiring  into  the  history  of  Pott's  disease,  one  is 
frequently  told  that  tiie  first  thing  noticed  was  the  angulation  of  the  spiiu'. 
With  some  trouble,  however,  one  can  usnally  obtain  information  of  a 
train  of  symptoms  introductory  to  the  actual  deformity. 


128  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

(1)  Latent  Period. — The  original  onset  can  frequently  be  traced  to  an 
attack  of  one  of  the  exanthemata,  and  probably  during  the  lowered  resistance 
of  convalescence  the  organism  first  gains  a  footing.  Before  any  definite 
and  specific  symptoms  are  complained  of,  the  child  exhibits  symptoms 
which  ought  to  attract  attention.  The  weight  does  not  continue  to  increase, 
it  remains  stationary,  or  it  diminishes.  The  general  nutrition  is  not  main- 
tained and  the  child  becomes  thin  and  pale.  There  are  slight  evening 
temperatures,  sometimes  so  slight  as  to  be  scarcely  perceptible.  The 
energy  is  lessened.  A  child  who  has  been  bright  and  active  becomes  dull 
and  listless,  refuses  to  indulge  in  the  games  of  its  comrades,  and  complains 
of  feeling  tired  after  the  slightest  exertion.  This  constitutes  what  one  may 
term  the  latent  or  the  introductory  period.  It  may  last  several  weeks  or 
as  many  months. 

(2)  Pain. — The  pain  in  Pott's  disease  may  be  of  the  nature  of  a  referred 
pain  or  of  a  local  pain.  The  local  pain,  that  is  to  say  the  pain  which  occurs 
in  the  region  of  the  spmal  column,  may  be  spontaneous  or  it  may  only  be 
induced  on  movement  or  pressure.  In  character  it  is  sharp  and  stabbing, 
and  it  is  more  especially  localised  to  the  actual  diseased  vertebra  or  vertebrae. 
When  judged  from  the  point  of  view  of  diagnostic  value,  one  attaches  less 
importance  to  it  than  to  the  referred  variety.  In  attempting  to  induce  the 
pain,  Kirmisson  recommends  the  examination  of  the  whole  length  of  the 
spine  by  percussion,  tapping  each  individual  spine  ■with  the  finger.  This 
method  has  two  fallacies.  In  a  nervous  child  the  mere  act  of  percussion 
produces  alarm,  and  pain  is  complained  of  when  it  is  not  really  present. 
Fm-ther,  there  are  areas  of  the  spine  which  one  may  term  normally  sensitive 
— the  sixth  cervical,  the  seventh  dorsal,  and  the  first  lumbar.  These  areas 
may  respond  to  percussion  in  such  a  way  as  entii'ely  to  mislead  one. 

Local  pain  may  be  tested  for  by  applying  over  the  spine  a  sponge  wrung 
out  of  hot  water.  When  it  is  brought  over  the  site  of  disease,  a  sudden 
sensation  of  pain  is  induced.  Ice-cold  water  may  be  used  for  the  same 
purpose,  producing  a  similar  eft'ect. 

Some  authors  have  recommended  the  use  of  an  electrode  with  a  constant 
current.  A  delicate  test  of  the  presence  of  pain  is  obtained  by  pressure 
upon  the  transverse  processes.  Rotation  of  the  bodies  occurs,  and  pain  is 
at  once  produced.  In  this  way  the  fallacy  of  pain  from  pressure  on  the  skin 
is  got  rid  of. 

A  local  pain  produced  by  movement  of  the  spine,  the  pain  being  accom- 
panied by  muscular  rigidity,  is  often  present.  Its  diagnostic  significance  is 
discussed  with  the  clinical  feature  of  spinal  rigidity. 

But  much  more  important  than  local  pain  is  the  presence  of  referred 
pain.  As  the  disease  in  the  spine  develops,  pressure  comes  to  be  exerted 
upon  the  nerve  roots,  and  according  as  these  are  distributed,  so  is  the  pain 
referred.  The  pain  is  usually  subacute,  but  it  is  subject  to  sudden  exacer- 
bation. Its  distribution  varies  when  different  regions  of  the  spine  are 
affected.  In  cervical  disease  it  may  be  referred  to  the  occiput  and  the  arm. 
Dorsal  disease  is  associated  with  sternal  or  intercostal  neuralgia,  dorso- 


TUBERCULOUS  DISEASE  OF  THE  SPINE  129 

lumbar  with  epigastric  and  girdle  pain,  lumbar  disease  with  pains  in  the 
hips  and  legs.  In  addition  to  the  pain  being  referred  to  a  certain  area, 
the  skin  over  the  area  of  distribution  is  hypersensitive  to  touch  and  to 
painful  stimuli. 

Referred  pain  is  the  most  common  cause  of  error  in  diagnosing  early 
Pott's  disease.  Epigastric  pain,  for  example,  is  frequently  judged  as  being 
due  to  indigestion,  when  in  reality  it  is  the  result  of  tuberculous  disease 
in  the  dorsal  spine. 

It  has  been  urged  that  it  is  important  to  induce  local  vertebral  pain  by 
sudden  pressure  upon  the  vertex,  the  pressure  being  exerted  with  the  patient 
erect.  This  is  a  perfectly  unnecessary  method  of  demonstration.  It  is 
painful  and  alarming,  and  any  knowledge  it  may  provide  can  easily  be 
determined  by  less  barbarous  means. 

(3)  Night  Cries. — These  are  not  so  common  in  Pott's  disease  as  they 
are  in  tuberculosis  of  the  larger  joints.  They  are  sometimes  met  with  when 
the  disease  affects  the  cervical  and  upper  dorsal  regions.  They  indicate  a 
progressing  state  of  the  disease,  and  they  correspond  to  the  pathological 
condition  in  which  the  vertebral  body  has  partially  but  not  entirely  collapsed. 
Night  cries  disappear  quickly  under  suitable  treatment. 

(4)  Symptoms  dependent  on  Paralysis. — Paralysis  occasionally  comes 
on  before  spinal  deformity,  and  by  doing  so  may  cause  confusion.  The 
symptoms  appear  gradually.  The  child  is  noticed  to  trip  and  stumble 
with  a  quite  unusual  persistence,  there  is  difficulty  in  going  up  or  in  coming 
down  stairs,  and  the  child  is  conscious  of  a  progressive  stiffness  and  tiredness 
in  the  extremities.  The  physical  signs  found  upon  examination  are  dis- 
cussed later,  sufficient  for  the  present  to  say  that  they  are  those  of  a 
spastic  paralysis,  with  no  involvement  of  sensation.  Such  early  symptoms 
as  have  been  mentioned  should  at  once  arouse  one's  suspicion  of  Pott's 
disease,  and  in  every  case  of  doubtful  paralysis  it  is  well  to  strip  the  child 
and  carefully  examine  the  back. 

(5)  Symptoms  dependent  on  Abscess  Formation. — These  vary  accord- 
ing to  the  position  occupied  by  the  abscess.  In  cervical  disease,  a  retro- 
pharyngeal abscess  being  the  most  common  complication,  one  may  find  the 
symptoms  of  dyspnoja,  hoarseness  of  voice,  and  difficulty  in  swallowing. 
When  the  disease  occurs  in  the  upper  dorsal  region,  and  the  abscess  takes 
up  an  anterior  position,  it  may  press  upon  the  recurrent  laryngeal  nerves, 
producing  dyspnoea  and  an  alteration  in  voice.  One  of  the  best  symptomatic 
evidences  of  abscess  formation  is  found  when  the  abscess  invades  the  sheath 
of  the  psoas,  producing  irritation  and  contraction  of  the  muscle.  The 
loading  symptom  is  tliat  of  difficulty  in  walking,  owing  to  the  persistent 
flexion  and  eversion  of  the  limb. 

Physical  Sig'ns. — Method  of  Examination  of  Patient. — In  examining 
a  case  of  Pott's  disease  one  ought  to  follow  a  definite  scheme.  The  results 
and  po.ssible  complications  of  the  disease  are  so  widespread  and  diffuse 
that  it  is  ea.sy  to  overlook  important  facts,  unless  some  routine  is  followed. 
(1)  At  one's  introduction  to  the  patient  one  has  an  opportunity  of  studying 

9  " 


130  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

the  body  attitude  and  gait.  There  are  many  jjoints  to  be  learned  from 
these  as  they  differ  in  each  situation-development  of  the  disease.  (2) 
One  notes  the  general  facial  appearance  and  body  nutrition.  (3)  The  spine 
is  inspected,  and  any  irregularities  noted  and  locahsed.  (4)  Some  form  of 
permanent  record  is  made  of  every  deformity  which  exists  in  the  spine.  (5) 
The  spinal  movements  are  tested,  each  tvpe  of  movement,  and  each  region 
of  the  spine  being  examined.  The  movements  are  examined  when  carried 
out  by  the  active  muscular  movements  of  the  child,  and  when  performed 
passively.  (6)  Certain  areas  of  the  body  are  carefully  examined  for  the 
presence  of  cold  abscesses.  (7)  The  reflexes,  superficial  and  deep,  are  tested, 
and  irregularities  of  sensation  or  movement  noted.  (8)  Compensatory 
changes  are  observed  as  they  occur  in  the  cranium,  the  thorax,  or  the  pelvis. 

(9)  The  heart  and  great  vessels  are  examined  by  the  usual  clinical  methods. 

(10)  The  examination  is  concluded  by  the  taking  of  one  or  more  X-ray 
photographs,  illustrative  of  the  portion  of  the  spine  affected. 

Such  is  the  scheme  which  one  adopts,  and  there  are  no  details  of  it  which 
can  afford  to  be  neglected.    We  shall  now  examine  each  feature  in  detail. 

1.  Attitude  and  Gait. — Peculiarities  of  attitude  are  usually  conspicuous. 
There  is  a  distinctive  general  attitude,  and  it  corresponds  to  what  one  may 
term  the  "  spring  "  type.  All  the  weight-bearing  joints  of  the  body  are  kept 
to  a  slight  degree  flexed.  The  child  walks  on  its  toes,  the  knee  and  hip 
joints  are  partially  flexed,  the  head  is  brought  down  to  the  shoulders,  and 
the  arms  hang  loose  by  the  side.  It  is  an  attitude  of  expectation,  produced 
by  the  constant  fear  of  sustaining  a  sudden  shock.  Every  joint  becomes 
a  spring  intended  to  minimise  an  injury,  and  all  acting  to  lessen  the  impact 
received  by  the  diseased  spinal  column. 

There  are  specific  attitudes  which  correspond  to  disease  in  different 
regions  of  the  spine.  In  cervical  disease  the  position  of  the  head  is  changed. 
It  may  assume  a  position  resembling  wryneck,  with  an  approximation  of 
the  ear  to  the  shoulder  tip,  but  without  that  rotation  of  the  face  which  is 
pathognomonic  of  wryneck.  Sometimes  the  head  is  thrown  well  back 
and  to  one  side.  Less  frequently  the  chin  droops  forwards  on  to  the  chest, 
and  the  head  is  supported  by  the  palms  of  both  hands.  Sa3rre  differentiates 
between  the  attitudes  when  the  disease  is  in  the  upper  or  in  the  lower  cervical 
region.  If  the  upper  cervical  vertebrae  are  affected,  the  head  takes  up  the 
position  resembling  wryneck.  If  the  disease  has  occurred  in  the  lower 
cervical  or  upper  dorsal  region,  an  effort  is  made  to  keep  the  head  in  balance 
by  pushing  the  chin  forwards  and  throwing  the  occiput  slightly  backwards. 

In  the  upper  dorsal  region  the  shoulders  are  raised,  gi^ang  the  appearance 
of  a  sunken  neck,  and  the  shoulders  and  arms  are  thrown  backwards  in  a 
stiff  military  attitude.  Owing  to  the  displacement  downwards  of  the  ribs, 
the  upper  part  of  the  chest  is  flattened,  and  the  lower  chest  and  the  end  of 
the  sternum  project  forwards. 

When  mid-dorsal  disease  is  present  there  is  considerable  spinal  rigidity 
and  early  deformity.  The  attitude  assumed  is  one  of  a  stiff,  rigid  back  ; 
both  arms,  which,  owing  to  the  displacement  of  the  vertebral  column,  appear 


TUBERCULOUS  DISEASE  OF  THE  SPINE  131 

longer  than  usual,  hang  down  by  the  side.     If  there  is  much  deformity 


Fig.   17. — The  position  of  the  head  in  various  varieties  of  cervical  disease.     (Jones  and  Ridlon.) 

A.  Wrynecli  position  :  disease  affecting  upper  two  or  three  cervical  vertebrce. 

B.  Hexed  position  :  disease  affecting  tlie  middle  cervical  vertebra?. 

C.  Extended  position  :  disease  affecting  tlie  lower  cervical  vertebrae. 

the  thorax  acquires  a  globular  shape,  with  upward  tilting  of  the  ribs  and 
displacement  of  the  whole  sternum  forwards. 

A  typical  attitude  is  noticed  when  the  disease  attacks  the  dorso-luinbar 


Fio.  18.  — Higli  dorsal  Pott's  disease. 
There  is  the  cliaracteristic  elevation 
of  the  slioulders. 


Flu.  19. — The  characteristic  attitude  of  high 
dorsid  disease.  The  short  neck,  tlie  higli 
slioulder.s,  and  tile  deep  chest  are  well  illus- 
trateil. 


and  upper  lumbar  regions.  The  head  and  upper  jjart  of  the  body  are 
thrown  backwards.  The  abdomen  is  prominent,  and  the  patient  stands  upon 
a  broad  base,  with  both  legs  well  apart.    He  walks  with  what  has  been  termed 


132 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


the  "  alderman's  gait,"  with  the  abdomen  projecting  and  the  chest  and 
shoulders  thrown  well  back.  He  tends  to  waddle  slightly  from  side  to  side. 
Pott's  disease  of  the  last  lumbar  vertebra  produces  a  deformity  to 
which  the  term  spondylohjsthesis  has  been  applied.  It  depends  upon  a 
destruction  of  the  body  of  the  last  lumbar  vertebra,  and  a  displacement 
forwards  and  downwards  of  the  lower  part  of  the  spinal  column.  The 
attitude  which  characterises  it  is  a  very  marked  lordosis  of  the  back  and 


Fig.  21. — High  dorsal  Pott's  disease. 


Fig.   20. — Dorso-liirabar   Pott's   disease. 
Tiiere  is  the  typical  "aldermau  gait." 

projection  of  the  belly  forwards.  The  thorax  is  depressed,  the  last  rib 
almost  touching  the  iliac  crest.  There  is  a  deep  transverse  fold,  which 
begins  upon  each  side  above  the  crest  of  the  ilium,  and  extends  across  the 
abdominal  wall  at  the  level  of  the  umbilicus. 

These  attitudes  and  gaits  are  so  typical  that  one  can  frequently  locate 
the  disease  in  those  who  pass  us  on  the  street. 

2.  General  Appearance  and  Body  Condition. — Sufierers  from  this 
disease  have  the  general  appearance  which  one  associates  with  tuberculosis 
elsewhere,  and  which  requires  no  detailed  description,  but  in  addition  they 
illustrate  in  their  features  the  presence  of  a  symptom  which  is  so  common 
in  bone  or  joint  disease,  that  of  pain.     The  facies  acquires  an  anxious  strained 


TUBERCULOUS  DISEASE  OF  THE  SPINE  133 

expression,  the  evidence  of  a  persistent  effort  to  prevent  the  sustaining  of 


Fia.  22. — Mill  dorsal  Pott's  disease. 
Slii^'lit  deformity. 


Fig.  23. — Low  dorsal  disease  with  spinal  rigidity 
and  no  Ijyphosis. 


Fio,  24. — Liow  dorsal  I'ott's  diseiise  with 
marked  deforniitv. 


Km.  25.  —  Low  dorsal  Pott's  disease. 


the  slightest  jar.     The  general  nutrition  of  the  bod}'  is  poor,  and  while  the 
disease  is  progressing  the  weight  probably  diminishes. 


134 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


3.  Inspection  of  the  Spine. — For  this  purpose  the  child  should  be 
stripped.  In  older  children  a  loose  skirt  may  be  fastened  around  the  hips  in 
such  a  way  as  to  expose  the  whole  extent  of  the  spine.     Running  one's  eye 


Fig.  26. — Donsal  Pott's  disease, 
with  slight  scoliosis. 


Fig.  27. — Dorsal  Pott's  disease, 
with  marked  scoliosis. 


along  the  vertebral  column,  one  may  have  the  attention  attracted  by  four 
possible  changes  :    (a)  A  posterior  angulation  of  the  spine  affecting  one  or 


Fig.  28. — Early  kyphosis  in  Pott's 
disease. 


Fig.  29. — An  unusual  form  of 
gibbosity  in  Pott's  disease. 


more  vertebrae  ;  (6)  A  lateral  deviation  of  the  spinal  column  ;  (c)  An 
unusual  degree  of  "  boarding  "  or  flattening  of  the  spine  ;  (d)  An  abnormal 
amount  of  spinal  lordosis. 

(a)  Posterior  Angulation  of  the  Spine.    Kyphosis. — This  is  the  most  strik- 


TUBERCULOUS  DISEASE  OF  THE  SPINE  135 

ing  of  the  deformities,  and  by  it  the  disease  usually  declares  itself.  It  is 
the  result  of  the  collapse  of  the  body  of  one  or  more  vertebra?.  If  a  single 
vertebra  is  destroyed  the  angulation  is  sharp,  and  produced  by  the  knuckle- 
like prominence  of  a  single  spine.  When  the  disease  has  occurred  in  several 
vertebrae  the  projection  is  more  rounded  and  diffuse.  One  expects  the 
amount  of  displacement  to  be  greatest  in  the  dorsal  spine,  less  in  the  cervical, 
and  least  of  all  in  the  lumbar  region. 

There  is  a  diffuse  superficial  tj^pe  of  tuberculous  disease  which  extends 
over  the  bodies  of  a  number  of  vertebrae,  and  gives  rise  to  a  gradual  kyphosis, 
very  strongly  resembling  the  simple  round  shoulders  of  adolescence. 

(6)  Lateral  Deviaiioti-  of  the  Spinal  Column.  Scoliosis. — It  is  by  no 
means  true  that  the  curvature  of  Pott's  disease  is  invariably  angular  and  in 
the  middle  line.     In  a  considerable  proportion  of  cases,  and  more  especially 


Via.  30. — Active  He.\iou  of  the  liealthy  spine  showing  a  iiniforni  and  conipletc  curve. 

in  the  lumbar  region,  the  destruction  of  the  vertebral  bodies  is  irregular, 
and  the  result  is  a  lateral  deviation  of  the  spine,  which  may  in  some  respects 
resemble  a  scoliosis.  In  these  cases,  in  almost  every  instance  an  angular 
curvature  by  means  of  which  one  may  distinguish  and  classify  the  disease 
is  added. 

There  is  another  variety  of  lateral  deviation  found  in  Pott's  disease 
which  is  liable  to  cause  confusion,  that  is  the  type  of  lateral  deviation  which 
occurs  at  the  very  commencement  of  the  disease,  before  there  is  any  appear- 
ance of  a  kyphotic  curvature.  At  first  sight  the  superficial  resemblance 
of  this  condition  to  a  simple  scoliosis  may  be  very  striking.  It  may  be 
recognised  by  its  rapid  onset,  and  the  concurrence  of  pain  and  muscular 
rigidity 

(c)  "  Boarding  "  or  Flattening  of  the  Spine.  The  hoaitliy  spine  ought  to 
present  a  series  of  uniform  curves.  An  interruption  of  those  curves,  as  in- 
dicated by  :iii  area  of  flattening,  is  evidence  of  some  underlying  muscular 


136 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


rigidity,  and  the  muscular  siJasm  is  itself  the  result  of  disease  of  the  vertebral 
column.  It  is  one  of  the  most  valuable  clinical  evidences,  because  it  is  perhaps 
the  earliest  to  make  its  appearance,  and  because  it  distinguishes  tuberculous 
disease  so  absolutely  from  simple  deformities.  The  phenomenon  becomes 
more  obvious  when  the  movements  of  the  spine  are  tested.  Its  distribution 
is  guided  by  the  situation  of  the  disease,  but  it  affects  the  muscles  for  some 
distance  upon  each  side  of  the  lesion.  The  explanation  of  the  muscular 
spasm  which  produces  the  rigidity  is  simply  that  it  is  an  attempt  to  im- 
mobilise the  diseased  spine,  and  so  to  lessen  the  amount  of  injury  which  it  is 


Fk;.  -il. — Passive  extension  in  a  healtliy  spine.     J^ote  the  free  and  nnil'orm  curve. 


liable  to  receive.  There  are  very  few  conditions  which  simulate  the  rigidity  of 
tuberculous  disease.  It  is  found  occurring  in  acute  and  subacute  infections 
of  the  vertebral  column,  and  in  the  more  painful  varieties  of  scoliosis. 

{d)  Abnormal  Degrees  of  Sjnnal  Lordosis. — When  a  kyphosis  occurs  in 
the  spinal  column,  the  alteration  which  the  displacement  must  produce  in 
the  axis  of  the  body  is  compensated  by  lordotic  cm-ves  in  other  situations. 
There  is  a  lordosis  above  and  below  the  lesion,  produced  at  first  by  muscular 
action,  and  later  by  an  adaptation  in  the  shape  of  the  intervertebral  discs. 
Cervical  disease  is  accompanied,  not  by  an  actual  lordosis  of  the  dorsal  spine, 
but  by  a  considerable  lessening  of  the  normal  kyphosis.  The  lumbar  region, 
however,  shows  an  increased  compensatory  lordosis.     A  tuberculous  dorsal 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


137 


kyphosis  is  compensated  by  exaggerated  lordotic  curves  in  the  cervical  and 
lumbar  regions.  When  the  disease  occurs  in  the  lumbar  region,  while  there 
can  be  compensation  above,  no  lordosis  can  exist  below.  Its  place  is  taken 
by  a  hyperextension  at  the  hip-joint. 

4.  The  Taking-  of  some  Form  of  Permanent  Record  of  the  Spinal 
Deformity. — It  is  exceedingly  important  to  keep  some  permanent  record  of 
the  spinal  deformity,  for  it  is  obviously  necessary  to  know  at  some  future 
visit  whether  the  deformity  has  increased  or  receded.  The  outlines  may  be 
cut  from  stiff  paper,  and  corrected  by  refitting  it  against  the  spine.  The 
actual  pattern  may  be  kept  for  future  reference,  or  its  outline  may  be 
transferred  to  soft  paper,'  which  can  be  rolled  up  into  small  bulk.  A  simple 
method  is  to  use  a  strip  of  lead  about  eighteen  inches  long  and  half  an  inch 


Flu.  32. — Young's  apparatus  for  recorJing  the  extent  of  a  spinal  deformity. 

wide  and  an  eighth  of  an  inch  in  thickness.  This  is  laid  along  the  spine  and 
carefully  moulded  to  the  outline  of  the  deformity.  From  it  a  tracing  is  made 
upon  paper,  and  the  tracing  is  kept  for  future  use. 

Dr.  (i.  B.  Young  of  Boston  has  introduced  an  ingenious  device,  by 
means  of  which  the  spine  outline  can  be  rapidly  delineated.  It  consists 
of  a  wooden  bar,  with  a  slot,  in  which  a  number  of  pieces  of  wood  of  equal 
lengths  play,  the  whole  being  clamped  in  place  by  a  screw  at  one  end.  When 
the  apparatus  is  set  upright  against  the  spine,  and  the  screw  loosened,  the 
individual  pieces  of  wood  adjust  themselves  to  the  outlines  of  the  spinal 
column.  When  the  screw  is  tightened,  the  exact  outline  is  retained  until 
it  has  been  transferred  permanently  to  paper.  A  useful  apparatus  has  been 
introduced  by  Beely.  It  consists  of  a  series  of  horizontal  movable  rods, 
fixed  in  a  vertical  stand,  and  capable  of  apposition  to  the  outline  of  the 
spine  when  the  patient  stands  erect.  The  pattern  is  transferred  from  the 
rods  to  paper. 


138 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


If  in  addition  to  the  kyphosis  there  is  some  scoUosis,  both  deformities 
cannot  be  recorded  upon  the  same  scheme.     A  separate  impression  must  be 

taken  of  the  scoliosis.  This  is 
conveniently  done  as  follows  : 
A  long  strip  of  netting  about 
18  inches  long  and  4  inches 
wide  is  used.  The  netting  has 
a  half-inch  mesh,  and  running 
lengthwise  along  its  centre  a 
coloured  line  is  marked.  The 
material  is  held  along  the  spine 
in  such  a  way  that  the  median 
line  lies  exactly  in  the  centre  of 
the  body,  as  judged  by  the 
seventh  cervical  vertebra  and 
the  natal  cleft.  The  line  of  the 
scoliosis  is  marked  out  upon 
the  netting  with  ink.  In  this 
way  a  permanent  record  can  be 
kept,  and  the  state  of  affairs 
compared  at  intervals.  Ebner  ^ 
records  the  amount  of  lateral  deviation  by  laying  a  strip  of  adhesive  plaster, 
3  inches  wide,  along  the  spine.  Upon  this  the  spinous  processes  are  marked 
and  outlined,  and  the  plaster  backed  with  brown  paper  for  future  reference. 


Fir.  33. — Free  lateral  luoveinent  of  the  liealtby  spiue. 


Fig.  34. — Passive  e.\tension  of  the  sjiine  demonstrates  "hoarding"  due  to 
dorso-lumbar  Pott's  disease. 

5.  Examination  of  the  Movements  of  the  Spine.    Muscular  Rigidili/. 
— The  possible  movements  which  the  spine  can  carry  out  are  those  of  flexion 
extension,  and  hyperextension  in  the  sagittal  planes,  lateral  flexion  in  the 

1  Ebner,  Archir.  pedirilr..  Feb.  1900,  07,  and  vi.  391. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


139 


coronal  plane,  and  rotation  or  torsion  about  its  own  long  axis.  Lateral 
flexion  and  rotation  cannot  exist  as  isolated  movements,  they  are  inter- 
dependent upon  one  another. 

When  tuberculous  disease  occurs  in  the  vertebrae,  it  gives  rise  to  a 
rigidity  in  the  long  para-spinal  muscles,  chiefly  the  erectores  spinse,  and  the 
resulting  rigidity  necessarily  interferes  with  the  carrying  out  of  the  proper 
spinal  movements.  Therefore,  of  all  signs  of  vertebral  disease,  muscular 
rigidity  is  the  most  characteristic.  While  the  interference  with  movement 
is  evidenced  in  all  the  movements,  it  is  most  striking  when  those  in  the 
sagittal  direction  are  performed.  In  each  region  of  the  spine  each  individual 
type  of  movement  ought  to  be  examined. 

The  Cervical  Spine. — In  the  cervical  spine  free  flexion  and  extension 
are  permitted  between  all  the  cervical  vertebrae,  and  nodding  movements 


Fig.  35. — Positioutestfornervicaldisea.se.  Tlie 
patiiMit  lying  prone,  tlie  head  ia  not  allowed  to 
bend  forwards.      (.Jones  and  Ridlon. ) 


Fi(i.  36.  —  Position  test  for  cerviial  disease.  Tlie 
patient  lying  supine,  the  head  is  not  allowed 
to  hang.     (Jones  and  Kidlon.) 


of  the  head  are  permitted  at  the  occipito-atlantal  articulation.  Lateral 
flexion  is  free  throughout  the  cervical  region.  Rotatory  movements  take 
place  chiefly  at  the  atlanto-axial  joints,  and  to  a  slight  degree  in  the  lower 
cervical  vertebrae. 

In  young  children  it  may  be  exceedingly  difficult  to  persuade  them  to 
carry  out  voluntarily  the  various  movements,  but  often  a  simple  manoeuvre 
overcomes  the  difficulty.  Place  the  child  on  its  back  across  its  mother's 
knees,  so  that  the  head  projects  without  support ;  if  the  spine  is  healthy, 
extension  is  carried  out,  and  the  head  falls  back.  By  reversing  the  position 
and  placing  tlie  cliikl  face  downwards  flexion  is  tested,  and  in  one  or  other 
lateral  posture  lateral  flexion  is  brought  into  i)lay.  Even  the  youngest 
child  can  be  persuaded  to  carry  out  rotation  by  the  judicious  exhibition  in 
varying  positions  of  attractive  bright  objects. 

The  movements  are  tested  passively  by  moving  the  head  in  the  direction 
required.     Oroat  care  nuist  be  exercised  in  doing  this  to  avoid  any  degree 


140  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

of  force,  as  when  the  disease  attacks  the  atlo-axial  articulation,  even  a  slight 
strain  might  produce  death  by  rupturing  the  transverse  ligament,  and  per- 
mitting dislocation  of  the  odontoid  process  and  pressure  upon  the  spinal 
cord. 

When  disease  attacks  the  vertebrae  of  the  cervical  spine  or  the  synovial 
sacs  at  its  upper  extremity,  there  is  produced  a  limitation  or  total  abolition 
of  the  spine  movements,  and  a  certain  degree  of  muscular  rigidity.  The 
muscular  rigidity  is  more  difficult  to  appreciate  than  when  it  is  lower  down 
in  the  spine,  but  it  may  be  appreciated  by  laying  the  palm  of  the  hand 
across  the  posterior  part  of  the  neck. 

Flexion  and  extension  and  lateral  flexion  are  limited  in  whatever  part 
of  the  cervical  region  the  disease  may  appear.  Rotation  is  only  moderately 
affected,  unless  the  disease  has  involved  the  atlanto-axial  joints. 

The  Dorsal  Spine. — All  four  movements  are  carried  out  by  the  dorsal 
spine,  and  it  is  easy  to  demonstrate  any  rigidity  which  may  exist.  The 
various  active  movements  are  attempted,  and  any  limitation  can  at  once 
be  noticed.  The  flexion  movement  is  the  more  valuable,  and  while  it  is 
being  performed,  the  spine  tips  ought  to  be  marked  out  with  colour.  In  the 
rigid  portion  of  the  spine  it  will  be  noticed  that  there  is  no  widening  of  the 
spaces  between  the  colour  dots  as  ought  to  occur  in  a  healthy  spine.  While 
the  part  is  moving  the  hands  ought  to  be  laid  upon  each  side  of  the  spine, 
and  they  appreciate  the  fact  that  where  the  disease  exists  several  of  the 
vertebrae  move  en  bloc. 

In  testing  the  active  movements,  it  is  a  common  manoeuvre  to  get  the 
child  to  pick  something  up  from  the  floor.  The  act  is  performed  with  none 
of  the  quickness  and  the  agility  of  health,  but  with  a  slow,  deliberate  action. 
Instead  of  bending  the  back  the  joints  of  the  lower  limbs  are  bent,  and  the 
trunk  is  supported  by  placing  both  hands  upon  the  knees.  In  recovering 
the  erect  position  the  hands  are  used  to  climb  up  the  thighs  in  much  the 
same  way  as  one  finds  occurring  in  pseudo-hypertrophic  paralysis.  Another 
favourite  method  of  testing  flexion  is  to  ask  the  child  while  it  is  sitting  up 
to  touch  the  toes  of  its  extended  legs. 

When  examination  of  the  active  movements  is  completed  the  passive 
movements  are  tested.  The  child  lies  completely  prone,  with  the  elbows 
flexed  and  the  arms  by  the  sides.  The  lower  limbs  are  grasped  by  the  ankles, 
and  gradually  raised  into  the  air.  As  the  lower  limbs  are  raised  the  spine 
ought  to  sink  into  an  almost  uniform  curve.  When  disease  is  present  the 
curve  is  not  uniform.'  A  portion  of  the  spine  remains  flat  and  rigid,  and  the 
trunk  is  lifted  from  the  table  with  the  lower  Hmbs  in  order  to  prevent  any 
sinking  of  the  column. 

The  Lumbar  Spine. — Examination  of  the  lumbar  spine  is  carried  out  in 
a  manner  similar  to  that  used  in  the  dorsal  region.  The  presence  of  rigidity 
is  best  tested  by  raising  the  lower  extremities.  By  this  act  the  healthy 
lumbar  spine  ought  to  be  hyperextended  ;  in  disease  it  remains  stift'  and 
rigid.  In  judging  of  the  value  of  lumbar  rigidity,  the  close  relationship  of 
the  psoas  muscle  to  the  lumbar  spine  must  be  borne  in  mind.     Anything 


TUBERCULOUS  DISEASE  OF  THE  SPINE  141 

which  by  irritation  produces  spasm  of  the  psoas  will  certainly  give  rise  to 
rigidity  of  the  lumbar  spine.  One  has  seen  typical  lumbar  rigidity  produced 
by  the  tracking  abscess  of  high  dorsal  tuberculous  disease  and  by  an  acute 
pelvic-rectal  abscess  which  had  entered  the  sheath  of  the  psoas  muscle. 
Palpating  the  spine  at  this  stage  one  may  be  able  to  recognise  the  presence 
of  thickening  around  the  spines  or  transverse  processes. 

6.  Examination  of  certain  Areas  for  the  Presence  of  old  Abscess 
Formation. — The  formation  of  these  and  the  course  most  usually  followed 
have  been  discussed.  The  back  of  the  throat,  sides  of  the  neck,  iliac  fossae, 
loins,  Poupart's  ligaments,  Scarpa's  triangles,  and  the  regions  of  the  gluteal 
folds  are  carefully  palpated  for  swelling  and  deep  fluctuation.  By  percussion 
and  by  X-ray  examination  a  mediastinal  or  prevertebral  abscess  may  be 
discovered.  A  psoas  abscess  may  be  suspected  before  it  becomes  palpable 
by  the  rigid  psoas  muscle  preventing  hyperextension  of  the  hip. 

7.  Examination  for  Paralysis. — The  j^aralysis  is  a  motor  one,  involv- 
ing usually  the  lower  extremities.  The  bladder  and  rectum  are  rarely 
affected,  and  it  is  unusual  to  have  any  sensory  disturbance.  It  is  the  result 
of  pressure  upon  the  spinal  cord,  and  one  has  mentioned  the  various  means 
by  which  pressure  may  be  exercised.  It  is  often  secondary  to  high  dorsal 
disease  because  in  this  situation  the  spinal  canal  is  narrowest. 

At  first  the  paralysis  is  a  spastic  one,  but  when  the  degeneration  of  the 
cord  becomes  advanced  the  paralysis  is  complete.  In  low  dorsal  and  lumbar 
disease  the  paralysis  affects  the  lower  limbs  and  sometimes  the  sphincters. 
In  this  situation  the  paralysis  may  be  complete  from  its  beginning,  or  it 
may  rapidly  pass  from  the  spastic  to  the  flaccid  variety.  In  dorsal  disease 
there  is  a  spastic  paralysis  of  the  lower  limbs  ;  it  is  unusual  to  find  the 
sphincters  affected.  If  the  disease  is  in  the  cervical  region,  the  arms  may 
suffer  before  the  legs.  In  specially  high  disease — occipito-atlantal  disease — 
the  diaphragm  may  be  paralysed,  also  the  spinal  accessory  and  hypoglossal 
nerves. 

In  the  examination  a  complete  investigation  must  be  made  of  the 
various  nerve  functions.  Motor  functions  are  tested  by  movements  and 
walking.  If  early  paralysis  is  i)rpsent,  movements  are  carried  out  in  a 
mi.sguided  and  jerky  manner.  The  child  walks  badly,  with  a  tendency  to 
lose  equilibrium  and  to  stumble,  the  toes  being  dragged.  Sensory  dis- 
turbances may  be  subjective  in  the  form  of  dull  aching  pains  in  the  body 
and  limbs.  Objectively  an  actual  loss  of  sensation  may  be  demonstrated. 
The  reflexes  superficial  and  deep  are  exaggerated,  especially  the  deep  re- 
flexes of  the  knee  and  ankle.  If  the  cord  is  degenerated,  or  if  the  lumbar 
enlargement  is  involved,  the  refle.xos  are  absent. 

Examination  of  the  sphincter  may  show  that  incontinence  of  urine 
and  faeces  occurs.  There  may  be  trophic  disturbances,  the  affected  muscles 
become  wasted,  bed  sores  are  not  unconnnon,  and  arthropathies  may  occur 
in  the  larger  joints  of  the  extremities.  Vasomotor  disturbances  show  them- 
selves in  the  form  of  per'^istent  coldness  of  the  limbs  and  a  tendency  to  free 
perspiration.     In   special   regions   specific    nerve    lesions   may   appear,   for 


142  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

example,  in  cervical  disease  the  cervical  sympathetic  may  be  afEected,  pro- 
ducing at  first  dilatation  of  the  pupil,  and  afterwards  contraction,  and  in 
many  cases  flushing  and  sweating  of  the  face  upon  one  side. 

8.  Compensatory  Chang-es  in  the  Cranium,  Thorax,  and  Pelvis. — 
These  have  been  fully  discussed  in  the  section  on  pathology.  The  changes 
are  now  studied  from  a  clinical  point  of  view.  The  alteration  in  the  position 
of  the  head,  the  possible  changes  in  the  obliquity  of  the  ribs  and  sternum, 
and  the  distortion  of  the  pelvic  girdle,  all  should  be  noted. 

9.  Examination  of  the  Heart  and  Great  Vessels. — When  a  kyphosis 
occurs  in  the  dorsal  region,  the  alteration  in  the  internal  anatomy  of  the 
thorax  may  very  seriously  affect  the  heart  and  the  large  vessels.  By  the 
usual  methods  of  clinical  examination,  the  presence  of  cardiac  hypertrophy 
and  dilatation  are  discovered,  valvular  disease  is  sought  for,  and  the  relative 
condition  of  the  large  blood-vessels  investigated. 

10.  X-Ray  Examination. — "When  clinical  examination  has  aiiorded  its 
information,  one's  knowledge  of  the  case  is  completed  by  X-ray  examination. 
Certain  facts  are  learned  which  otherwise  might  remain  obscure.  The  degree 
of  the  disease  is  estimated,  and  its  extent  is  depicted.  The  presence  of  an 
otherwise  unsuspected  prevertebral  abscess  may  be  demonstrated  and  the 
situation  of  sequestra  divulged.  When  the  disease  is  healing,  X-ray  exam- 
ination will  yield  information  of  how  the  cure  is  progressing.  The  radio- 
graph is  taken  antero-posteriorly,  but  in  the  cervical  region  a  lateral  view  is 
necessary  in  order  to  expose  the  upper  true  vertebrae.  Antero-posteriorly 
they  are  concealed  by  the  presence  of  the  lower  jaw. 

Symptoms  and  Sigrns  in  Special  Reg-ions. — The  symptoms  and  signs 
vary  in  different  parts  of  the  spine,  and  while  they  have  been  discussed 
generally,  it  is  necessary  to  individualise  in  sjiecial  regions. 

(a)  Upper  Cervical  Disease. — Here  the  disease  really  begins  as  a  syno- 
vitis, involving  the  occipito-atloid  and  atlo-axoid  articulations,  from  which 
it  spreads  to  the  underlying  bones.  The  odontoid  process  is  early  affected, 
and  also  the  anterior  arch  of  the  atlas. 

In  the  introductory  stages  of  the  disease  the  leading  symptoms  are 
those  of  difficulty  in  moving  the  head,  local  pain  over  the  sjDine,  and  referred 
pain  radiating  about  the  back  of  the  head  and  along  the  course  of  the  upper 
cervical  nerves.  Pressure  upon  the  vertex  causes  pain,  the  movements  of 
nodding  and  rotation  are  limited  or  abolished,  there  may  be  a  deformity 
which  closely  resembles  wryneck,  and  the  hollow  of  the  suboccipital  region 
frequently  becomes  filled  up. 

In  the  absence  of  treatment  the  amount  of  pain  increases,  the  weight 
of  the  head  becomes  unbearable,  and  the  patient  supports  his  head  on 
his  hands  or  by  lying  down.  An  abscess  may  form  and  take  up  the  position 
of  a  retropharyngeal  collection  or  of  an  accumulation  in  the  suboccipital 
region.  At  any  moment  grave  symptoms  of  spinal  compression  may  appear 
as  the  result  of  a  thickening  of  the  soft  tissues  or  of  a  displacement  of  the 
bones.  In  the  latter  case  the  odontoid  process  is  most  frequently  to  blame, 
and  immediate  death   may  occur.     Much   more   commonly   the   paralysis 


TUBERCULOUS  DISEASE  OF  THE  SPINE  143 

comes  on  as  an  increasing  feebleness  of  the  limbs,  the  arms  being  usually 
first  affected  and  then  the  lower  extremities.  WTien  recovery  takes  place, 
ankylosis  is  usually  the  result. 

(6)  Cervical  and  Cervico-dorsal  Disease. — In  this  region  the  spinal  rigidity 
is  very  apparent,  and  there  are  probably  the  associated  deformities  of  wry- 
neck, shortening  of  the  neck,  and  angular  curvature.  In  upper  dorsal 
disease  the  position  of  the  ribs  becomes  altered,  and  they  pass  almost 
vertically  downwards,  reducing  the  antero  -  posterior  diameter  of  the 
thorax.  Pain  is  present,  and  it  is  referred  to  the  branch  distribution 
of  the  cervical  or  brachial  plexuses.  If  abscesses  appear  they  are  retro- 
pharyngeal, supraclavicular,  or  mediastinal  in  position. 

Cord  pressure  effects  are  iiot  so  common  as  in  the  other  regions  of  the 
cord.  If  they  occur  the  upper  extremities  are  usually  first  affected,  and 
afterwards  the  lower  limbs.  Very  often  there  are  nerve  pressure  effects, 
pupillary  changes  from  sympathetic  pressure — myosis  or  mydriasis — 
recurrent  laryngeal  and  vagus  effects,  as  evidenced  by  cough,  slow  pulse, 
vomiting,  etc.  There  may  be  the  characteristic  signs  of  turning  the  head 
and  body  to  look  at  an  object,  and  in  upper  dorsal  disease  the  grunting 
breathing  which  denotes  pressure  on  the  intercostal  nerves. 

(c)  Dorsal  and  Dorso-lumbar  Disease. — The  deformity  of  the  spine  is 
usually  striking,  and  from  the  displacement  upwards  of  the  ribs  and  the 
projection  forwards  of  the  sternum,  the  antero-posterior  diameter  of  the 
thorax  is  increased.  There  may  be  local  spine  pains  and  referred  pams  which 
are  of  the  girdle  variety.  Sometimes  pains  are  referred  down  the  lower 
limbs. 

Paralysis  is  common  in  disease  of  the  mid-dorsal  region  ;  it  is  not 
so  frequent  in  lumbar  disease.  When  the  pressure  is  at  the  level  of  the 
lumbar  enlargement  the  limbs  remain  flaccid,  the  reflexes  are  feeble  or 
abolished,  and  there  is  incontinence  of  urine  and  faeces. 

(d)  Lumbosacral  Disease. — There  is  usually  only  a  slight  amount  of 
deformity.  Sometimes  a  vertebral  thickening  indicates  the  site  of  the 
disease.  Occasionally  the  somewhat  rare  deformity  of  spondylolysthesis 
occurs.  The  pelvis  is  apt  to  be  deformed,  and  in  children  it  may  become 
funnel-shaped.  Pain  is  present,  and  it  is  referred  chiefly  to  the  outer  side 
of  the  thighs. 

The  nerve  troubles  which  result  are  due  to  neuritis,  and  therefore  they 
are  chiefly  local  in  their  distribution,  affecting  iiulividuai  groups  of  nuiscles 
which  are  not  necessarily  symmetrical  or  bilateral. 

Diagnosis  of  Pott's  Disease 

The  diagnosis  of  Pott's  disease  offers  few  ditliculties  if  deformity  is 
present,  but  from  the  point  of  view  of  successful  treatment  it  is  essential 
that  the  disease  should  be  recognised  while  it  is  in  its  earliest  stages.  The 
diagnosis  is  made  to  a  certain  extent  from  the  history,  but  more  especially 
from  the  physical  examination.     The  most  important  point  in  history  is 


144  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

the  occurrence  of  referred  pain,  referred  to  the  arms  or  legs  or  the  anterior 
middle  line  of  the  body.  Sternal  or  epigastric  pain  in  a  child  should  at  once 
suggest  the  possibility  of  Pott's  disease.  Referred  pain  is  of  more  value 
than  local  pain  as  a  diagnostic  feature.  More  productive  than  symptom- 
atology is  the  physical  examination.  Muscular  spasm  is  one  of  the  first 
signs  to  appear.  In  exceptional  cases  its  duration  is  a  short  one,  and  it 
may  be  overlooked,  but  it  occurs  at  some  period  in  every  instance.  It 
should  be  evidenced  on  active  and  on  passive  movement.  When  the  angular 
deformity  is  visible  the  diagnosis  may  be  said  to  be  removed  beyond  doubt. 

Abscess  formation  may  be  among  the  first  signs  of  Pott's  disease,  and 
it  is  important  to  remember  that  a  cold  abscess  may  appear  suddenly  :  even 
in  the  course  of  a  single  night.  This  more  especially  happens  when  the 
abscess  appears  in  a  dependent  position. 

It  remains  to  mention  the  importance  of  recognising  early  spastic 
paralysis  ;  it  may  appear  before  there  are  any  other  evidences  of  spinal 
disease. 

The  type  of  Pott's  disease  in  which  compression  symptoms  come  on 
without  any  vertebral  irregularity  may  give  rise  to  considerable  difficulty 
in  diagnosis.  The  subject  is  exhaustively  dealt  ■nnth  by  Alquier,^  whose 
papers  ought  to  be  consulted. 

An  X-ray  examination  is  unnecessary  for  making  a  diagnosis  in  the 
majority  of  cases,  but  in  doubtful  instances  it  may  be  of  inestimable  value. 

Differential    Diagnosis. — The    differential  diagnosis  only  presents 
difiiculties  in  the  early  stages,  and  at  this  period  many  experienced  surgeons  , 
have  been  at  fault.     There  are  cases  which  appear  to  conform  to  no  rules, 
the  symptoms  of  which  appear  absolutely  contradictory. 

Tuberculous  disease  of  the  cervical  spine  may  be  confounded 
with  : 

(1)  Torticollis. — This  one  recognises  by  the  presence  of  shortened 
muscles  and  fasciae,  the  rotation  of  the  face  towards  the  opposite  shoulder, 
and  the  hemiatrophy  of  the  face. 

(2)  Stiff  Neck,  Acute  Wryneck. — The  attitude  of  this  condition  may 
strongly  suggest  cervical  caries,  but  it  may  be  distinguished  by  the  acuteness 
of  its  history,  and  the  rapidity  with  which  it  yields  to  treatment. 

In  the  upper  dorsal  spine  simple  round  shoulders  with  stiffness  may 
simulate  Pott's  disease.  The  former  lacks  the  muscular  spasm  of  the 
tuberculous  condition,  and  any  dubiety  remaining  may  be  removed  by  the 
use  of  the  X-rays. 

Dorsal  Pott's  disease  is  simulated  by  : 

(1)  A  Rachitic  Kyphosis. — The  points  of  distinction  in  favour  of  rickets 
are  the  absence  of  muscular  spasm,  the  non-existence  of  pain,  and  the 
evenness  of  the  kyphotic  curve. 

(2)  Simple  Scoliosis. — The  diagnosis  of  this  condition  is  generally  easy. 
There  is  usually  absence  of  muscular  rigidity  and  pain,  and  the  rotation  of 
the  vertebrse  and  ribs  produces  the  typical  posterior  rib  hump.     In  scohosis 

'  Alquier,  Gaz.  des  hopitaux.  May  19,  1906,  and  Feb.  19,  1907. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  145 

the  ribs  rotate  backwards  on  the  convex  side,  in  caries  on  the  concave 
side. 

(3)  Syphilitic  Kijphosis. — This  condition  is  rare  in  children,  and  it  can 
only  be  distinguished  by  the  occurrence  of  other  sypliihtic  phenomena. 

(4)  Spinal  Neuralgia. — An  error  which  is  frequently  made  consists 
in  confoundinji;  vertebral  disease  with  what  has  been  called  spinal  neuralgia. 
This  latter  occurs  in  nervous  young  girls,  and  there  are  many  features  which 
differentiate  it  from  tuberculosis.  The  pain  is  much  more  diffuse,  and 
extends  over  a  considerable  part  of  the  vertebral  column.  It  is  more 
superficial  and  much  more  acute.  The  rigidity  so  characteristic  of  Pott's 
disease  is  entirely  absent.' 

(5)  Anatomical  Abnormalities. — In  the  lower  dorsal  region  an  anatomical 
abnormality  is  sometimes  met  with  which  may  raise  difficulties  in  diagnosis. 
The  abnormality  consists  in  an  unusual  prominence  of  certain  of  the  verte- 
bral spines  closely  simulating  a  kyphosis.  The  physical  examination  is 
sufficient  to  establish  a  distinction. 

The  Lumbar  Spine  is  the  situation  in  which  the  most  difficulties  in 
diagnosis  arise.  There  are  several  reasons  for  this.  The  lumbar  vertebrae 
are  more  deeply  situated,  and  physical  signs  are  therefore  apt  to  be  masked 
for  a  considerable  time.  The  movements  of  the  lower  part  of  the  spine  are 
so  limited  that  neither  sjinptoms  nor  deformity  may  constitute  prominent 
features  in  the  case. 

Confusion  may  arise  with  the  conditions  which  have  been  mentioned  in 
the  diagnosis  of  dorsal  disease.  In  addition  there  are  certain  difficulties 
which  are  peculiar  to  this  situation. 

(1)  Hip-joint  Disease. — It  might  seem  impossible  that  this  could  be 
mistaken  for  lumbar  disease,  but  mistakes  are  frequently  made.  From  a 
focus  in  the  lumbar  spine  a  cold  abscess  tracks  its  way  into  the  psoas  muscle 
and  sheath.  Contraction  of  the  psoas  is  set  up,  and  there  is  produced  a 
deformity  of  the  leg  with  flexion  and  eversion  of  the  thigh.  Superficially 
the  attitude  resembles  that  found  in  hip-joint  disease.  The  most  satisfactory 
method  of  differentiation  is  that  of  testing  the  movements  of  the  hip. 
In  coxitis  all  the  movements  are  limited  or  abolished.  In  the  pseudo- 
coxitis  of  lumbar  disease  extension  and  hyperextension  are  the  only  move- 
ments which  are  markedly  interfered  with.  In  exceptional  instances  lumbar 
disease  and  hip  disease  may  co-exist.  Parsons  '  draws  attention  to  a  most 
important  point  in  the  differential  diagnosis  of  hip  disease  from  spinal  caries. 
The  distinction  is  based  upon  the  principle  laid  down  by  John  Hilton,  that 
the  same  trunks  of  ncrvt^s,  the  branches  of  which  supply  the  groups  of 
muscles  moving  any  joint,  furnish  also  a  distribution  of  nerves  to  the  skin 
over  the  same  muscles  and  their  insertions,  while  the  interior  of  the  joint 
receives  its  nerves  from  the  same  source.  A  hip-joint  may  be  fixed  by  muscu- 
lar spasm,  which  is  the  result,  not  of  disease  of  the  joint,  but  of  irritation  of 
the  nerve  trunks  by  a  lumbar  caries.  A  distinction  is  made  by  noting  the 
distribution  of  the  cutaneous  pain.     In  lumbar  disease  the  affected  cutaneous 

'  Parsons,  B.M.J.,  I'JIO,  ii.  112(1. 

10 


146  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

distribution  would  include  the  fi-ont  of  the  lower  part  of  the  abdomen,  the 
front  of  the  thigh,  the  region  over  the  great  trochanter,  and  to  the  inner  side 
of  the  knee.  In  hip  disease,  the  cutaneous  affection,  in  addition  to  the 
above,  includes  the  distribution  of  branches  of  the  sacral  plexus,  because  the 
interior  of  the  joint  is  partly  supplied  by  branches  from  the  nerve  to  the 
quadratus  femoris  and  from  the  great  sciatic.  The  cutaneous  distribution 
of  these  branches  is  limited  to  the  skin  over  the  buttock  and  the  upper 
and  back  parts  of  the  thigh. 

(2)  Sacro-iliac  Disease. — Sacro-iliac  disease  is  distinguished  by  the 
absence  of  spinal  rigidity  and  the  elicitation  of  pain  at  the  synchondrosis 
by  pressing  the  two  iliac  bones  together  anteriorly. 

(3)  Perinephritis  and  Perityphlitis. — These  in  children  may  simulate 
Pott's  disease,  because  they  are  associated  with  contraction  of  the  psoas 
muscle.  A  distinction  is  made  by  examination  of  the  spine,  the  abdomen, 
and  the  urine,  and  by  an  X-ray  investigation. 

If  there  is  much  difficulty  in  coming  to  a  diagnosis  it  is  a  good  plan  to 
temporise,  keeping  the  child  in  complete  recumbency  for  a  few  days.  Pott's 
disease  remams  unaltered  at  the  end  of  the  period.  Simulating  conditions 
may  have  disappeared. 

Prognosis  in  Pott's  Disease 

The  prognosis  as  regards  life  is  good.  Tuberculous  meningitis,  for 
example,  claims  fewer  victims  in  Pott's  disease  than  it  does  in  hip-joint 
disease.  If  death  should  occur  the  causes  in  addition  to  meningitis  are' 
pulmonary  tuberculosis,  acute  miliary  tuberculosis,  amyloid  degeneration 
of  the  spleen,  liver,  and  kidneys,  and  exhaustion.  The  prognosis  is 
exceedingly  grave  when  the  disease  occurs  during  the  first  two  years  of 
life.  The  life  prognosis  is  endangered  by  formation  of  abscesses,  sinuses 
with  mixed  infection,  and  the  spread  of  tubercle  elsewhere. 

The  ultimate  duration  of  life  is  not  a  long  one.  Neidert  ^  has  shown  that 
of  all  cured  cases  of  Pott's  disease  attaining  adult  life,  the  total  expectation 
of  life  was  not  more  than  49|  years.  This  is  almost  entirely  the  result  of 
kinking  and  displacement  of  the  larger  vessels,  with  consequent  hypertrophy 
and  dilatation  of  the  heart  chambers. 

The  prognosis  as  to  the  amount  of  deformity  depends  very  largely  upon 
the  condition  of  the  spine  at  the  time  treatment  is  begmi.  If  the  disease 
is  early,  appropriate  and  thorough  treatment  ought  to  prevent  any  marked 
degree  of  kyphosis  occurring.  If  a  kyphosis  has  occurred,  but  has  not  yet 
become  a  fixed  one,  corrective  measures  may  be  employed  to  diminish  the 
deformity. 

As  regards  the  effect  of  the  situation  of  the  disease,  cases  of  cervical 
and  lumbar  caries  recover  with  less  deformity  than  do  the  dorsal  ones,  on 
account  of  the  physiological  lordosis  which  is  already  existent,  and — this 
applies  to  the  lower  lumbar  spine — the  slight  degree  of  movement  which 
occurs. 

^  Neidert,  Inaugural  Dissertation,  Munich,  1886. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  147 

The  prognosis  of  the  duration  of  treatment  varies  considerably  in  dorsal 
disease,  it  probably  should  not  be  less  than  four  to  five  years.  In  cervical 
and  lumbar  disease,  for  reasons  stated  above,  the  duration  often  does  not 
exceed  three  years. 

Treatment  of  Pott's  Disease 

The  treatment  of  Pott's  disease  is  general  and  local. 

General  Treatment. — The  principles  embodied  in  this  line  of  treat- 
ment have  been  already  fully  discussed.  The  patient  should  have  an 
abundance  of  nourishing  food,  and  be  kept  out  of  doors  as  much  as  is  possible. 
As  recumbency  is  an  important  factor  in  the  local  treatment,  a  spinal  carriage 
must  be  provided  in  which  the  patient  can  be  wheeled  about  from  place  to 
place.  The  whole  day  is  spent  out  of  doors,  and  at  night  the  child  should 
sleep  in  a  shelter,  which  during  winter  may  be  artificially  heated.  Under 
conditions  such  as  these,  children  improve  very  rapidly.  The  use  of  drugs 
is  unsatisfactory,  with  the  exception  of  these  which  act  as  general  tonics. 

Local  Treatment. — The  principles  underlying  the  local  treatment 
of  Pott's  disease  aim  at  removing  from  the  focus  the  dangerous  influences  of 
movement,  weight,  and  pressure  ;  to  fix  the  spine,  as  it  were,  in  splints,  and 
having  fixed  it,  to  hold  it  so. 

The  Principles  of  Mechanical  Treatment.— Normally  the  weight 
of  the  head,  and  often  the  weight  of  the  thoracic  and  abdominal  viscera, 
tend  to  bend  the  spine  forwards  and  downwards.  This  is  resisted  by  the 
posterior  spinal  muscles.  If  the  body  of  a  vertebra  becomes  destroyed, 
the  tendency  to  bend  is  increased,  and  the  pressure  of  superincumbent 
weight  in  the  upright  posture  is  a  most  important  factor  in  the  production 
of  the  deformity.  Therefore  the  principles  in  mechanical  treatment  are  : 
(1)  To  support  the  back  and  to  prevent  further  bending  ;  (2)  To  extend 
the  back,  and  so  diminish  the  strain  on  the  posterior  muscles  ;  (3)  To  apply 
traction,  and  thus  prevent  antero-posterior  deformity. 

Local  treatment  may  be  divided  into  two  groups  :  (.4)  Treatment  by 
recumbency  ;  (B)  Ambulatory  treatment.  The  value  of  each  varies  accord- 
ing to  the  age  of  the  patient,  the  state  of  the  disease,  and  the  portion  of  the 
spine  affected. 

A.  Recumbency. — This  method  consists  in  keeping  the  patient  lying 
in  such  a  position  that  movements  of  the  spine  are  abolished,  and  all  weight 
bearing  is  removed  from  the  vertebra). 

Indications. — The  indications  for  its  use  are  as  follows  :  (1)  In  cases  of 
Pott's  disease  which  come  under  treatment  before  a  spinal  deformity  has 
appeared.  (2)  Whenever  the  symptoms  are  acute  (pain).  (3)  When  am- 
bulatory treatment  has  been  tried  and  has  failed  to  give  satisfaction.  (4) 
When  paralysis  has  appeared,  or  is  threatening.  (5)  When  the  spinal  disease 
is  complicated  by  a  lateral  deviation  or  a  p.soas  contraction,  either  of  which 
complications  render  an  ordinary  support  inefficient.  (6)  When  abscess 
formation  has  occurred. 


148  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

Explanation  of  Benefit. — The  question  may  be  asked,  What  is  the  reason 
of  the  improvement  which  results  from  the  treatment  ?  That  there  is  great 
improvement  is  obvious  to  every  one  who  has  seen  the  method  employed. 
The  pain  disappears,  the  irritability  diminishes,  the  patient  gains  in  weight, 
and  the  face  loses  its  anxious  tense  expression.  The  explanation  of  the 
improvement  may  be  said  to  be  a  double  one.  Tuberculous  disease  is  an 
inflammatory  lesion,  and  in  common  with  all  inflammatory  lesions,  it  benefits 
from  the  provision  of  complete  rest.  Recumbency  ensures  this  rest.  The 
second  explanation  depends  upon  the  counteraction  of  muscular  spasm. 
Muscular  rigidity  is  the  result  of  a  certain  degree  of  destruction  of  the  body 
of  the  vertebra.  Essentially  it  is  protective,  being  nature's  method  of  lessen- 
ing the  possible  movement  of  the  diseased  part,  but  actually  it  is  productive 
of  further  harm.  The  eroded  vertebra,  imder  the  constant  strain  of  the 
contracted  muscles,  gradually  gives  way.  As  it  does  so,  the  diseased  bone 
surfaces  come  together,  and  a  further  reflex  spasm  is  set  up,  in  fact  a  vicious 
circle  is  brought  into  action.  When  the  vertebral  body  has  partially 
collapsed  the  shortening  of  the  anterior  spinal  muscles  places  these  at  a 
mechanical  advantage  over  the  posterior  ones,  and  the  continued  contrac- 
tion of  the  former  increases  and  aggravates  the  deformity.  If  recumbency 
is  properly  carried  out,  it  provides  more  than  simple  rest  to  the  spine  ;  it 
ought  to  provide  some  degree  of  counter-extension,  an  opening  out  of  the 
collapsing  vertebra,  and  a  lengthening  of  the  contracted  anterior  muscles. 
The  muscular  balance  is  restored,  the  spinal  deformity  is  lessened,  and 
as  the  diseased  surfaces  do  not  now  irritate  one  another,  the  symptoms  are 
relieved. 

Disadvantages. — There  are  certain  disadvantages  associated  with  re- 
cumbency. When  the  case  is  an  out-patient,  with  imperfect  home  condi- 
tions, it  is  exceedingly  difficult  to  ensure  that  the  treatment  is  being 
thoroughly  and  conscientiously  carried  out.  Yielding  to  the  entreaties  of 
the  child,  an  unscrupulous  mother  will  allow  the  child  to  sit  up  in  spite  of 
the  most  solemn  warning  of  the  danger  it  may  entail.  Parents  frequently 
complain  of  the  trouble  which  there  is  in  carrying  the  child  about.  Un- 
doubtedly this  is  a  disadvantage  ;  it  may  be  minimised  by  the  use  of  a 
spinal  carriage  or  go-cart.  In  many  of  the  reciimbent  methods  nursing  is 
carried  on  at  a  disadvantage.  This,  however,  does  not  apply  to  the  more 
recent  introductions. 

Advantages. — The  advantages  far  outbalance  the  disadvantages.  They 
are  the  relief  of  pain,  the  arrest  and  improvement  of  the  deformity,  the 
gradual  improvement  of  paresis,  and  the  arrest  of  the  increase  in  size  of  an 
abscess. 

Appliances. — Of  the  various  appliances  for  securing  recumbency, 
mention  will  be  made  of  a  simple  bed  prepared  for  recumbency ;  Tubby's 
spinal  pillow  ;  Fisher's  frame  ;  the  double  Hamilton  splint  ;  the  double 
Thomas  splint  with  head  -  piece ;  Bradford's  bed  frame  ;  "WTiitman's 
stretcher  frame  ;  the  plaster  bed  of  Lorenz  and  Hoffa  ;  GauvaLn's  spinal 
board  ;   the  back  door  splint ;   the  wheelbarrow  splint. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


149 


Fig.  37. — Bed  arranged  for  the  recumbenuy  treatiueut  of 
Pott's  disease. 


Special  Requirements. — Any  application  to  be  suitable  must  fulfil  four 
requirements  :  It  must  permit  of  easy  nursing  ;  it  must  ensiue  absolute 
rest  to  the  spine  ;  the  apparatus  when  applied  should  provide  a  certain 
degree  of  hyperextension  of  the  vertebral  column  ;  if  double  extension  is 
necessary,  the  splint  must  be  of  such  a  kind  that  extension  apparatus  can  be 
easily  applied  to  it.  Each 
type  of  apparatus  will  now 
be  examined  in  detail. 

Bed  specially  adapted 
to  Reciimbency.  —  There 
are  patients  who  refuse  to 
allow  any  treatment  which 
is  associated  with  the  ap- 
plication of  splints,  and 
yet  are  quite  willing  to 
undergo  recumbency  as 
long  as  it  is  carried  out 
in  bed.  For  this  reason, 
and  occasionally  for  that 
of  expense,  it  becomes 
necessary  to  fit  up  a  bed  in  such  a  way  that  the  treatment  is  possible.  The 
bed  employed  must  be  a  narrow  one,  as  it  facilitates  the  nursing  ;  and  it 
ought  to  be  provided  with  wheels  in  order  to  permit  of  the  patient  being 
wheeled  into  the  open  air. 

It  is  essential  that  the  patient  should  lie  upon  a  firm,  unyielding  surface, 
otherwise  sagging  of  the  spine  and  increased  deformity  will  occur.  A  suit- 
able surface  is  provided  by  placing  beneath  the  mattress  an  ordinary  broad 
fracture  board.  The  usual  head  pillows  must  be  removed,  but  two  small 
oblong  pillows  ought  to  be  attached  to  the  sheet  in  such  a  way  that  they 
lie  one  on  each  side  of  the  vertebral  column,  opposite  the  kyphosis.  A  simple 
ring  pad  may  be  allowed,  to  prevent  pressure  upon  the  back  of  the  head,  but 
there  must  be  no  employment  of  air  or  water  cushions. 

The  position  of  the  patient  in  bed  is  a  matter  about  which  there  is 
difference  of  opinion.  In  cervical  caries,  when  extension  becomes  necessary, 
the  dorsal  position  is  essential,  but  when  disease  attacks  the  dorsal  or  the 
lumbar  spine,  either  the  supine  or  the  prone  position  may  be  chosen.  The 
supine  position  is  the  more  comfortable,  but  it  may  tend  to  aggravate  a 
deformity.  The  prone  position  is  certainly  uncomfortable,  but  it  diminishes 
muscular  spasm,  it  counteracts  the  deformity,  and  it  certainly  lessens  the 
congestion  of  the  spine.  The  clothing  worn  by  tlie  patient  is  important. 
Flannel  ought  to  be  used,  and  the  garments  ought  to  take  the  form  of  night- 
gowns, which  can  be  put  on  from  the  front  and  button  at  the  back. 

Some  form  of  retention  apparatus  requires  to  be  fitted  to  the  bed. 
Efficient  fixation  is  given  by  two  broad  straps,  one  passing  across  the  chest 
at  the  level  of  the  upper  chest,  and  ringed  to  fit  each  shoulder,  the  other 
passing  at  the  level  of  the  iliac  bones.     Both  of  these  straps  are  made  cheaply, 


150 


TUBEECULOSIS  OF  THE  BONES  AND  JOINTS 


yet  quite  efficiently,  of  strong  canvas.  When  they  are  fastened,  the  buckles 
must  be  upon  the  under  part  of  the  bed,  otherwise  they  are  being  continually 
undone  by  the  child.     If  it  is  considered  desirable  to  fasten  the  lower  limbs, 


Fig,  38. — Head  extension  .applied  for  tuberculous  disease  of  the  cervical  spiue. 

they  are  best  secured  by  a  simple  ring  or  clove  hitch  round  the  ankle,  fastened 
by  a  strap  to  the  lower  posts  of  the  bed.     Narrow  sand  pillows  must  be 


Fig.  39. — Tubby's  spinal  pillow. 

available  in  case  it  is  necessary  to  fix  a  part,  and  wooden  blocks  are 
required  to  tilt  the  end  of  the  bed  dming  extension. 

\Mien  extension  becomes  necessary  it  may  be  applied  as  single  or  as 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


151 


double  extension.  When  it  is  applied  to  the  lower  extremities,  the  foot  of 
the  bed  is  raised  to  provide  the  counter-extension  of  the  body.  The  limbs 
are  extended  by  weights  passing  over  pulleys,  or  by  elastic  bands  fastened 
to  the  limbs  and  to  the  foot  of  the  bed.  In  head  extension  the  upper  end  of 
the  bed  is  raised,  and  a  bridle  attached  to  the  head,  with  straps  passing 
beneath  the  chin,  below  the  occiput,  and  around  the  forehead.  The  point 
of  junction  of  these  straps  is  fastened  upon  each  side  of  the  head  to  a  weight 
apparatus. 

Tuhby's  Spinal  Pillow. — Tubby  has  introduced  a  pillow  which  is  a  com- 
fortable and  useful  means  of  treatment.  His  own  description  of  the  article 
is  quoted  :  ^ 

I  have  designed  and  largely  used  a  pillow,  which  is  placed  beneath  the 
seat  of  the  disease  and  for  some  distance  above  and  below  it.  It  is  convex 
from  above  downwards,  and  is  centrally  grooved  in  the  same  direction  so  as  to 
receive  the  spinous  processes,  whilst  pressure  is  made  upon  the  transverse 
processes.  It  is  stifiened  in  the  required  situations  with  felt.  To  each  side  of 
the  pillow  two  pieces  of  stay  material  are  attached.  The  upper  pieces  from 
each  side  are  of  such  a  size  and  so  provided  with  lacing  that  they  can  be  laced 
across  the  chest,  and  help  to  keep  the  child  recumbent.  The  lower  pieces  on 
each  side  are  fixed  by  safety  pins,  or  by  stitching  them  to  the  sheet  and  mattress 
so  as  to  prevent  movement  or  any  attempt  at  turning  over.  If  the  pillow  itself 
is  covered  with  macintosh  it  is  easily  cleaned.  After  a  month  or  so  it  requires 
making  up  again,  as  the  effect  of  constant  pressure  is  to  flatten  it.  Its  use 
prevents  deformity  in  early  cases,  and  helps  its  recession  and  sometimes  its 
disappearance. 

This  apparatus  has  one  disadvantage  in  so  far  as  it  is  difficult  to  fit  it 
up  with  extension  appliance. 
The  difficulty  which  is  ex- 
perienced in  providing  exten- 
sion on  a  bed  or  pillow  may 
be  obviated  by  using  a 
Fisher's  Bed  Frame,  in  which 
the  extension  is  carried  from 
the  shoulders,  and  fixation 
at  the  same  time  secured. 
From  the  extremities  of  a 
transverse  bar,  which  lies 
above  the  head,  two  vertical 
bars  are  hinged  in  such  a 
way  that  they  extend  down- 
wards one  along  each  side  of 
the  body ;  where  they  pass 
beneath  the  shoulders,  leather 
loops  arc  attached,  through 
which  the  patient's  arms  are  passed  ;  from  the  transverse  bar  two  leather 
or  elastic  bands  extend  to  the  bed  rail.     It  is  a  cheap  and  an  easy  fitting 

'  Tubby,  loc.  sup.  cit.,  vol.  ii.  p.   I  Kl. 


Fiii.  40. — Kislier's  beil-fraiue  lor  the  tiTiitinciil  of  Pott's 
(liauase  by  lecumbeiicy.  The  frame  keeps  the  patient 
ill  tile  reeiiiiibeiit  jmsitioii. 


152 


TUBEECULOSIS  OF  THE  BONES  AND  JOINTS 


appliance,  but  the  degree  of  recumbency  which  it  induces  is  insufficient 
unless  it  is  combined  with  body  bands  of  some  description. 

The  Double  Hamilton  Splint. — In  out-patient  hospital  work  this  is  a 
favourite  type  of  splint,  its  chief  recommendation  being  the  easiness  and 
rapidity  with  which  it  can  be  made,  and  the  comparative  cheapness  of  the 
completed  article.  It  can  only  be  employed  in  mid-dorsal  and  dorso-lumbar 
disease,  and  at  best  it  provides  but  imperfect  fixation.  Two  pieces  of  wood 
extend  one  upon  each  side  of  the  body,  from  the  axillae  to  about  six  inches 


Fig.  41.— The  double  Hamilton 
splint. 


Fig.  42.  —  The  double  Thomas 
splint  for  use  in  Pott's  disease 
or  double  hip  disease. 


beyond  the  feet.  These  two  lateral  halves  are  fastened  together  by  a 
transverse  bar,  which  extends  between  the  lower  ends  at  a  level  just 
above  the  heel.  The  distance  between  the  lower  ends  of  the  splint  varies, 
but  the  most  suitable  position  for  nursing  is  one  of  slight  double  abduction. 
The  contact  portions  of  the  splint  are  well  padded.  The  limbs  are  fastened 
to  it  by  ordinary  roller  bandages,  the  body  by  means  of  a  binder.  The 
special  disadvantages  of  the  splint  are  its  non-control  of  the  upper  part  of 
the  vertebral  column,  the  posterior  sagging  of  the  spine,  and  the  trouble 
which  there  is  in  securing  the  bandages. 

The  Double  Thomas  Splint. — This  form  of  spUnt  is  useful,  especially 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


153 


when  it  is  fitted  with  a  support  for  the  cervical  spine.  The  usual  pattern 
can  be  improved  by  a  few  alterations.  The  ordinary  double  Thomas 
hip-spUnt  is  made  by  joining  two  single  splints,  united  by  the  chest  band 
above  and  a  cross  bar  below.  In  adapting  the  splint  to  spinal  use,  the  two 
vertical  pieces  are  carried  in  upon  each  side  to  near  the  middle  line,  so  that 
they  lie  upon  the  transverse  processes  of  each  side.  They  end  opposite 
the  posterior-superior  spines  of  the  iliac  bones,  where 
they  are  attached  to  a  semicircular  piece  extending 
outwards  upon  each  side.  The  ends  of  this  semi- 
circular portion  pass  down  the  posterior  aspects  of 
the  thighs  as  in  an  ordinary  double  Thomas  splint. 
The  vertical  spinal  portions  are  moulded  to  fit  any 
kyphosis  which  may  be  present.  The  moulding  ought 
to  be  somewhat  less  than  the  degree  of  actual  bend, 
as  in  this  way  some  degree  of  extension  is  maintained 
on  the  spine.  The  efficacy  of  the  support  is  con- 
siderably increased  by  fitting  to  the  body  transverse 
some  vertical  apparatus  which  will  control  the  head 
and  neck.  The  advantages  of  the  splint  are  the  ease 
with  which  the  patierrt  can  be  carried  about,  the 
degree  of  fixation  which  it  affords,  the  continuous 
hyperextension,  and  the  facility  of  nursing.  Its  dis- 
advantages are  its  expense,  and  the  degree  of  care  ^''"'- ''''■~''^™°''.'^,'"V^°"'^'^ 

...  .■-  T,^i»  Thomas    splint   for    use 

With  which  it  requires  to  be   made  and  fitted.     A       h,  pott's  disease. 
badly-fitting  splint  of  this  type  is  worse  than  useless. 

Bradford  Bed  Frame. — The  bed  frame  of  Bradford  keeps  the  patient 
in  a  horizontal  recumbent  position.  It  is  a  rigid  rectangle,  usually  made  of 
four  pieces  of  |-inch  galvanised  iron  gas-piping,  screwed  into  an  elbow  at 
each  corner  ;  one  elbow  has  a  reverse  screw  to  allow  of  putting  the  whole 
together.  The  width  should  be  equal  to  the  distance  between  the  shoulder 
tips,  and  the  length  a  few  inches  more  than  the  height  of  the  patient.     The 

rectangle  is  wound 
with  two  pieces  of 
cotton  sheeting,  double 
thickness,  with  a  four- 
inch  space  between  the 
two  pieces  to  permit  of 
nmsing.  The  covers 
are  cut  to  three  times 
the  width  of  the  frame,  they  are  doubled  and  laced  behind  with  a  sail  needle 
and  strong  cord.  Two  linen  pads  are  placed  upon  the  canvas  opposite  the 
diseased  portion  of  the  spine.  They  exert  no  pressure  upon  the  spinous 
processes,  but  instead  thoy  raise  and  hyperoxtcnd  the  spine.  The  child 
wears  an  undershirt  and  a  cotton  night-gown,  opening  behind. 

To  prevent  the  patient  wriggling  about,  he  is  secured  to  the  frame  by 
two  webbing  straps,  buckled  round  the  frame  and  across  the  chest  like  a 


Fig.  44. — The  Bradford  bed  frame.     Thi.s  e.vami)le  is  fitted  witli 
cross  straps.     It  may  he  fitted  wifli  a  corset  arrangement  instead. 


154 


TUBEECULOSIS  OF  THE  BONES  AND  JOINTS 


soldier's  cross  belts,  the  buckle  being  on  the  under  surface  of  the  frame. 

Two  loops  are  with  advantage  fastened  to  the  canvas  in  order  to  secure 

the  shoulders.  The  pelvis 
is  secured  by  a  broad  binder 
pinned  round  the  frame, 
and  the  knees  by  a  towel. 
No  pillow  is  allowed,  or  only 
a  flat  ring-pad.  In  attend- 
ing to  the  hygiene  of  the 
back,  the  child  is  laid  face 
downwards,  the  splint  re- 
moved, and  the  back  bathed 
with  alcohol  and  powdered 
with  talc. 

In  feeding,  some  diffi- 
culty may  be  experienced 
at  first  in  the  taking  of 
fluids.  This  can  be  over- 
come by  using  a  "  feeding 
duck  "  or  tube.  The  child 
and  splint  can  be  completely 
wrapped  up  in  blankets,  and 
there  is  no  danger  of  catch- 
ing cold. 

This  is  a  most  excellent 

Pig.  45.— Tlie  Bradford  bed  frame  for  Pott's  disease.  ^^rm    of    splint  ;    it   is    Com- 

fortable, cheap,  and  effica- 
cious. It  is  suitable  for  a  lesion  in  any  part  of  the  spinal  column,  and  if 
extension  becomes  necessary,  this  can  be  easily  adjusted  to  either  end. 


Fig.  46. — The  Bradford  frame  for  the  treatmeut  of  Pott's  disease.     Tlie  spiue  is  kept  extended 
by  pads  fastened  to  the  canvas  of  the  frame  on  each  side  of  the  spine  opposite  tlie  Icyjihosis. 

Whitman  Stretcher  Frame. — This  is  very  similar  in  character  to  the 
Bradford  frame,  but  it  carries  out  a  continual  hyperextension.  It  is  much 
narrower,  and  it  is  bent  so  as  to  he  convexly  upon  the  back  opposite  the 
kyphosis.  It  is  made  of  iron  gas-piping,  and  while  it  is  about  six  inches 
longer  than  the  child,  it  is  of  such  a  breadth  that  the  sides  of  the  frame  lie 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


155 


opposite  the  glenoid  cavities  and  the  acetabula.  The  cover  is  a  single 
piece  of  stout  canvas,  laced  posteriorly  from  end  to  end.  Upon  the  canvas 
felt  pads  three-quarters  of  an  inch  thick  are  sewed,  so  as  to  press  upon 
either  side  of  the  spinous  process  at  the  level  of  the  deformity. 

The  patient  is  fastened  to  the  frame  by  an  apron,  which  extends  over 


Fia.  47 


-The  Whitiiiau  frame  for  the  treatnieut  of  Pott's  disease.     Tlie  frame  is  bent 
opposite  the  kyphosis. 


the  abdomen  and  the  lower  chest,  and  is  fastened  by  buckles  to  the  under 
surface  of  the  canvas  upon  each  side.  At  first  the 
frame  is  bent  slightly  opposite  the  angulation  on  the 
spine.  The  bend  is  increased  each  day  until  the  de- 
formity and  the  physiological  dorsal  curve  have  become 
obliterated.  When  the  frame  is  sufficiently  arched, 
double  traction  is  exerted  by  the  weight  of  the  head 
and  the  legs. 

The  child  should  be  clothed  in  a  cotton  under- 
vest,  but  the  outer  garment  should  include  both  the 
frame  and  the  child. 

The  splint  possesses  all  the  advantages  of  the 
Bradford  frame,  and  in  addition  it  possesses  the 
benefit  of  keeping  up  a  continual  hyj^erextension. 
It  is  perhaps  less  comfortable  than  the  Bradford 
frame  on  account  of  its  narrowness,  and  the  unin- 
terrupted stretch  of  canvas  makes  the  nursing 
slightly  more  difficult. 

The  Planter  Bed.^~A  jjlaster  shell  is  fitted  to  the 
back,  and  in  it  the  patient  is  kept  recumbent.  To 
make  it,  an  ordinary  hammock  is  arranged,  and  upon 
it  the  patient  is  laid  face  downwards.  By  adjusting 
the  hammock  screw  the  spine  can  be  hyperextended  to 
different  degrees.  A\Tien  the  hypercxtension  is  suit- 
able, the   patient's  skin   is   well   oiled,   and  the   hair 

^'"i.^^'iT"^"?'^'^"  cuirass,  protected    with   linen    pads.      Plaster    bandages    are 

IJonble  extension  is  on-    ^  _  ^  ~ 

tallied  by  the  liead  .siiiij;  applied  evenlv  over  the  back,  from  the  top  of  the 
and  by  traction  from  ),p.,^j  ^,,  j^  ,f  ^^.;  bpt^^-pg,,  tjie  gluteal  fold  and  the  bend 
tne    feet,     for   use   in  •  *" 

Pott's  disea.se.  of  iW  knee.     It  is  advised  to  apply  five  layers  of 

bandages   running   ])arailel   to   the   long  axis  of   the 

body,  three  layers  extending   radially  from   the  deformity,  and  two  layers 

'    Holla,  hrhrhiirh  drr  orlhnpadischen  C'hir.,  \i.  .'tl:t. 


156 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


to  the  sides  of  the  bed  in  straight  longitudinal  turns.  The  shell  is 
completed  by  numerous  cross  turns,  binding  the  whole  fabric  together. 
Weak  points  are  strengthened  by  incorporating  strips  of  aluminium,  wire- 
gauze,  or  cotton  padding  wrung  out  of  plaster  cream. 

When  the  case  is  well  hardened  it  is  lifted  off,  and  the  patient's  back 
washed  and  dried.  The  walls  of  the  plaster  bed  are  carefullysmoothed  and  cut 
away  from  the  arm-pits.  The  case  is  then  thoroughly  dried,  and  varnished 
outside  and  inside  \\ith  shellac.  When  it  is  thoroughly  dry  the  interior  is 
lined  with  padded  muslin,  stork  linen  being  specially  fitted  to  the  portion  over 
the  buttocks.  The  patient  is  secured  in  the  bed  by  circular  turns  of  bandage. 
The  above  is  the  simplest  method  of  making  the  plaster  bed,  but  it 
possesses  one  disadvantage.  When  the  plaster  is  moulded  directly  to  the 
skin,  it  allows  of  no  after-contraction  in  the  plaster,  and  when  the  bed  is 
completed,  it  may  be  found  that  it  fits  so  tight  as  to  be  distinctly  uncom- 
fortable, more  especially  when  the  thickness  of  lining  is  added.  It  is 
therefore  preferable  to  first  take  a  plaster  cast  of  the  entire  back.  Plaster 
bandages  are  applied  directly  to  the  oiled  skin,  and  carefully  moulded  to 
the  anatomical  irregularities.  When  the  casing  is  hard  it  is  removed,  and 
the  inner  surface  having  been  well  oiled,  a  positive  is  taken  either  by  filling 
the  shell  with  plaster  or  by  means  of  a  layer  of  plaster  bandages.  When 
the  positive  is  thoroughly  dry,  its  size  is  increased  by  covering  it  evenly 
with  a  thin  layer  of  plaster  of  Paris  about  one-quarter  of  an  inch  in 
depth.  Upon  this  the  plaster  bed  is  moulded  as  described 
above,  and  there  is  now  no  risk  of  a  misfit. 

This  appliance  gives  perhaps  the  most  complete  and 
absolute  recumbency  of  all  others,  but  it  possesses  many 
disadvantages.  Its  manufacture  is  diSicult,  tedious,  and 
uncertain  ;  although  one  would  expect  it  to  be  comfort- 
able, it  is  as  a  matter  of  fact  most  irksome  ;  it  is  readily 
broken  ;   and  its  weight  is  a  distinct  drawback. 

It  is  difficult  to  apply  traction,  but  it  may  be  done  by 
cutting  away  the  head  portion,  and  using  head  bands  with 
weight  and  pulley.  A  jury-mast  may  be  used,  the  upright 
being  incorporated  in  the  wall  of  the  plaster  bed. 

Helbing  ^  strongly  advocates  the  use  of  the  plaster  bed 
during  the  active  stage  of  the  disease.  He  considers  it 
excellent  in  the  treatment  of  very  young  children,  and  he 
continues  it  for  one  to  three  years. 

Phelps'  ^  Bed  is  made  in  a  slightly  different  way.  A 
thin  board  is  cut  to  the  outline  of  the  body  and  the  extended 
legs.  It  is  padded  with  wadding  and  covered  with  cotton 
cloth.  The  patient  is  placed  upon  it,  and  plaster  bandages 
are  applied  to  encase  the  body  and  the  legs.  Later  the  front  is  cut  away 
so  that  the  jJatient  may  be  removed  from  the  bed. 


Fig.  49.— Phelps' 
plaster  bed. 


'■  Helbing,  Berlin  klin.  Wochenschr.,  Nov.  13  and  20,  1905. 
'  Phelps,  Trans.  Amer.  Orlh.'  Assoc,  1891,  iv.  83. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


157 


Gauvain's  Spinal  Board. — This  is  a  modification  of  the  board  used  at 
the  Maritime  Hospital,  Berck-sxir-mer.^  It  has  been  modified  by  Gauvain 
of  Alton,  and  his  description  of  the  apparatus  is  quoted  :  ^ 

The  board  consists  of  an  oblong  tray  made  of  strong  but  hght  wood.  The 
length  should  be  from  12  to  18  inches  longer  than  the  patient,  and  the  width 
about  8  inches  greater  than  his  greatest  width.  The  sides  of  the  board  are 
about  the  same  height  as  an  ordinary  Phelps'  box,  roughly  3  or  4  inches,  with  the 
exception  of  the  foot  end,  which  is  raised  to  a  height  of  from  15  to  18  inches, 
and  thereby  takes  away  from  the  patient's  feet  the  weight  of  the  bed  clothes, 
and  tends  to  prevent  the  onset  of  foot  drop.  The  bottom  of  the  board  is  per- 
forated with  numerous  holes  to  admit  ample  ventilation  of  the  mattress.  The 
corners  are  bound  with'  sheet  -  iron  angle 
pieces.  .  .  .  Across  the  board  is  placed  a 
piece  of  wood  of  suitable  height,  usually  2  to 
3  or  4  inches,  and  of  almost  the  same  width, 
which  stretches  from  one  side  of  the  board 
to  the  other,  and  is  designed  to  be  placed 
immediately  under  the  most  prominent  part 
of  the  angular  curvature.  It  is  fixed  by 
means  of  two  iron  pins,  which  serve  a  double 
purpose.  (1)  To  retain  the  cross-piece  in 
position ;  (2)  To  indicate  at  a  glance  where 
on  the  patient  the  angular  curvature  is. 

A  firm  pillow,  if  fixed,  forms  a  suitable 
substitute  for  the  wooden  cross  -  piece,  a 
well-prepared  horse-hair  mattress  occupies 
the  tray  over  the  cross-piece,  and  on  it  the 
patient  reclines.  At  the  head  and  foot  ends 
of  the  board  are  slits  cut  for  the  hands  to 
facilitate  transport.  At  the  head  end  of ' 
the  board  two  pieces  of  strong  elastic  web- 
bing, 1  inch  wide  and  about  6  inches  long, 
are  attached,  and  to  them  a  bridle  can  be 
buckled  when  head  extension  is  desired. 

At  the  foot  end  ...  are  two  longitudinal  slits,  through  which  the  cords  of 
a  leg  extension  can  be  passed  over  a  suitable  pulley.  This  pulley  is  fixed  to 
two  perforated,  upright  pieces  of  wood,  attached  to  the  board  on  each  side  of 
each  longitudinal  slit,  and  these  are  so  arranged  that  between  them  an  upright 
extension  rod  can  be  arranged  if  there  is  much  flexion.  .  .  .  The  patient  is  fixed 
to  the  board  in  a  simple  and  effective  manner.  A  jacket  composed  of  stout 
jean,  fitted  accurately  to  the  body  and  preferably  stificncd  with  whalebone, 
encases  the  patient.  On  the  back  of  the  jacket  two  strips  of  webbing  are  let 
in,  which  strips  cross  each  otlier  as  a  St.  Andrew's  cross,  and  these  are  buckled 
to  the  sides  of  the  board,  and  effectually  prevent  the  patient  from  moving  in 
any  direction,  and  keep  him  in  the  exact  position  which  has  been  decided  upon 
as  desirable.  The  jacket  should  be  laced  and  buckled  over  the  front  of  the 
patient. 

This  splint  has  many  advantages  :  it  is  simple,  light,  efficacious,  and 
convenient.     It  possesses  two  disadvantages  :    the  first  is  the  tendency 

'  Menard,  Etude  pratique  sur  le  mal  de  Pott,  Masson  et  Cie,  1900. 
*  Gauvain,  "  Tho  Mechanical  Treatment  of  Spinal  Caries,"  Lancet,  March  4,  1911. 


Fig.  50. — Gauvain's  spinal  board. 


158 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


towards  the  development  of  pressure  sores,  the  second  is  the  Uability  for  the 
jacket  to  loosen,  permitting  movement  which  depreciates  its  value. 

Gauvain's  Back-Door  Splint. — The  great  majority  of  splints  have  the 
common  disadvantage  that  if  they  are  to  be  efficacious  m  controlling  the 
spine,  there  will  result  a  corresponding  difficulty  in  attending  to  the  hygiene 
of  the  back.  To  overcome  this  difficulty,  Dr.  Gauvain  has  introduced  what 
he  calls  the  back-door  splint.     The  original  description  of  it  is  quoted  : 

Measurement  of  the  Splint. — The  patient  is  stretched  on  his  back  ou  a  piece 
of  paper,  the  head  is  held  by  one  assistant  and  the  legs  by  another,  and  the 
contour  of  the  trunk  is  traced  out.  The  splint  should  be  a  shade  smaller  than 
the  contour  of  the  trunk.  The  bottom  of  the  splint  should  be  jiist  above  the 
natal  cleft.  The  tracing  is  then  cut  out  and  a  piece  of  beech-wood  cut  to  exactly 
a  similar  size.  Well-seasoned  beech  is  especially  chosen,  because  experiment 
has  shown  that  it  is  very  strong,  that  it  does  not  warp  readily,  and  it  has  the 
additional  advantage  of  being  cheap.  The  outer  part  of  this  is  cut  away  1  inch 
from  the  perijihery  all  round,  forming  an  outer  frame.     This  is  covered  with 


FlQ.  51. — Gauvain's  back-door  splint.      The  door  has  lieen  removed  and  is  being  held  to  the  left. 


sheet-iron  screwed  to  the  frame,  and  forms  a  strong  and  rigid  framework.  The 
iron  is  then  lacquered  to  prevent  it  rusting  when  subjected  to  the  heat  and 
moisture  of  the  body.  The  inner  part  or  back  door,  which  fits  into  the  outer 
frame  accurately,  is  pared  down  a  little  so  that  it  can  be  removed  and  replaced 
with  great  ease,  and  is  perforated  with  holes  for  a  double  purpose — both  to 
ventilate  and  to  assist  in  fixing  the  padding  which  is  later  to  be  applied  to  it. 
The  Padded  Outer  Frame  and  Back  Door. — The  outer  frame  is  padded 
evenly  all  round,  but  especial  care  must  be  taken  in  padding  that  part  which  will 
come  in  contact  with  the  sacrum.  The  padding  should  be  perfectly  even,  and 
the  best  material  to  employ  is  animal  wool,  because  this  never  cakes,  and  has  a 
springiness  and  elasticity  which  make  it  peculiarly  suitable  for  this  purpose. 
The  padding  is  firmly  bound  down  to  the  splint  by  splint  hnen,  and  should  be 
covered  on  the  lower  part  with  jaconet  to  prevent  it  being  soiled  or  saturated 
if  the  patient  is  not  able  properly  to  control  his  evacuations.  The  back  door  has 
on  the  lower  aspect  a  suitable  handle,  which  facilitates  its  introduction  or  re- 
moval from  the  outer  frame.  It  is  kept  in  position  by  four  small  clips,  which 
are  attached  to  the  outer  frame.  The  surface  of  the  back  door  next  to  the  body 
is  also  padded  thickly  with  animal  wool,  and  this  padding  should  be  especially 
thick  and  firm  at  the  site  of  the  disease,  so  that  due  hyperextension  of  the  spine 
may  be  obtained.  It  will  be  found  convenient  to  use  tape  in  the  fixing  of  the 
splint  lining  in.stead  of  ordinary  thread,  as  with  the  tape  the  padding  can  be 
made  more  secure  and  much  more  durable.  The  patient  is  fixed  on  to  this  splint 
by  means  either  of  a  jacket  or  by  webbing.     Webbing  is  simpler  to  apply  and  is 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


159 


better  in  warm  weather,  but  the  jacket  is  neat,  and  gives  the  apparatus  a  more 
finished  appearance  when  in  use.  If  a  jacket  is  employed  it  will  be  found  most 
convenient  to  attach  it  to  the  outer  frame  on  its  inner  side,  and  the  jacket  should 
be  made  in  two  pieces,  each  in  duplicate,  so  that  should  it  become  soiled  the 
soiled  portion  can  be  immediately  removed  and  replaced.  In  any  case  it  would 
be  desirable  to  remove  the  jacket  at  intervals  so  that  it  may  be  cleaned — about 
once  monthly  is  commonly  sufficient.  To  facilitate  the  removal,  it  will  be  found 
convenient  to  employ  patent  placket  fasteners.  By  the  use  of  these  the  jacket 
can  be  removed  with  the  greatest  ease  and  speed,  and  be  instantly  replaced. 
The  jacket  should  be  strapped  and  laced  over  the  front  of  the  patient,  as  in  the 
manner  described  previously.  Should  webbing  be  used  in  place  of  the  jacket, 
a  piece  of  webbing  should  come  over  each  shoulder.  Two  pieces  should  come 
round  the  trunk,  and  all  should  be  fixed  to  the  inner  side  of  the  outer  frame  of 
the  splint.  They  should  be  buckled  appropriately  on  the  front  of  the  trunk. 
It  will  be  found  that  by  employing  a  splint  of  this  nature  the  patient's  back  can 
be  attended  to  without  the  j)atient  being  moved,  and  with  the  very  greatest  ease. 


Fk;.  52. — Giiuvain's  posterior  suspensory  splint. 


When  extension  becomes  necessary  it  can  be  arranged.  iFor  head 
extension  a  simple  bridle  may  be  employed,  or  the  outer  framework  of  the 
splint  may  be  prolonged  on  each  side  of  the  head  to  terminate  in  an  upright 
iron  bar,  to  which  the  bridle  is  attached  by  elastic  extension.  In  dorsal 
or  lumbar  disease,  extension  is  obtained  by  swinging  the  patient  in  his  splint, 
so  that  the  head  and  the  lower  extremities  are  gradually  dependent.  The 
same  result  may  be  obtained  by  mounting  the  outer  frame  of  the  splint  upon 
short  legs,  the  head  and  the  legs  being  dependent. 

The  Wheelbarrow  Splint. — WTien  there  is  spinal  disease  associated  with 

spasm  of  the  psoas 
muscle  or  with  a  psoas 
abscess,  Dr.  Gauvain 
has  introduced  what  he 
calls  "  the  wheelbarrow 
splint."  The  back- 
door splint,  already 
described,  is  made,  and 
supported  upon  four  short  logs.  The  patient's  legs  are  attached  to  posterior 
splints,  which  are  fixed  to  the  splint  frame  by  special  hinges  which  permit  of 
abduction,  adduction,  and  hyperextension,  but  no  degree  of  flexion,  inver- 
sion, or  eversion.     When  it  is  desired  to  ap[)ly  extension  to  the  lower  limbs, 


53.  —  Gauvain's  wlieelbarrow  .splint. 


160 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


small  wooden  foot-splints  are  fastened  on,  and  the  extension  strapping  is 
fastened  directly  to  them.  In  this  way  the  entii-e  weight  of  extension 
comes  directly  on  the  splint.  Head  extension  may  be  applied  by  means  of 
a  bridle. 

Phelps'  Box. — This  is  a  good  sphnt  for  use  among  the  poorer  class  of 
patients.  It  is  best  understood  by  reference  to  illustrations.  A  shallow 
wooden  box  is  made  to  fit  the  patient's  entire  stature,  both  legs  being  slightly 
abducted.  The  required  shape  is  cut  with  a  fret-saw  from  a  flat  piece  of 
beech  wood,  and  boards  of  sufficient  depth  are  screwed  to  the  sides.     Lateral 


Fig.  54. — Phelps'  box. 


Fia.  55. — Phelps'  bo.\  with  patient  iu  position. 


slits  are  cut  to  accommodate  the  shoulders.  The  box  is  lined,  and  a  cushion 
is  fixed  to  the  bottom  opposite  the  situation  of  the  spinal  prominence.  At 
each  of  the  upper  angles  of  the  box  curved  steel  supports  are  fastened,  and 
to  these  supports  a  chin  strap  is  secured.  It  is  impossible  to  apply  extension 
to  the  lower  limbs. 

Recumbency  in  Application  to  Special  Regions. — Cervical  Region. — 
Disease  in  the  cervical  spine  has  two  peculiarities,  which  render  the  choice 
of  recumbent  splints  rather  limited.  These  peculiarities  are  :  (1)  The 
difficulty  in  properly  fixing  the  head  and  neck  ;  (2)  The  necessity  in  many 
cases  of  applying  extension. 

The  patient  may  be  kept  in  a  bed  prepared  for  recumbency,  but  special 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


161 


Fia.  56. — The  U -shaped  pillow  arranged  for  the  treatment  of 
tuberculous  disease  of  the  cervical  spine. 


precautions  must  be  taken  in  regard  to  the  head  and  neck.    If  head  extension 

is  in  use,  it  is  sufficient  to  fix  the  head  laterally  by  two  heavy  sand-bags, 

placed  one  on  each  side 

of  the  head.     Around 

the  sand-bags  a  towel 

is  rolled,    and    passed 

across    the     forehead. 

If  no  head  extension 

is    applied,    a    special 

sand  -  pillow    is    used, 

shaped  Uke  a  IJ .     The 

transverse  part  of  the 

U   is  about   2    inches 

thick,    and    it    lies 

against  the  nape  of  the 

neck.       The    limbs    of 

the  U  are  much  larger 

and  heavier,  being  about  6  inches  in  depth  ;   they  lie  one  on  each  side  of 

the  head ;  a  narrow  towel  is  fastened  as  before  round  the  Umbs  of  the 
sand-bag  and  across  the  forehead. 

The  Bradford  frame,  the  ^^^litman  frame,  and  Gauvain's  spinal  board 
are  excellent  for  use  in  cervical  disease.  In  each  of  these  the  head  and  neck 
is  partially  controlled,  and  extension  can  be  readily  applied.  Phelps's  box 
is  useful,  and  also  the  plaster  bed,  if  it  is  made  to  include  the  head  and  neck  ; 
but  the  usefulness  of  both  is  lessened  by  the  difficulty  in  fastening  extension 
apparatus. 

Dorsal  Region. — When  expense  has  to  be  avoided,  a  dorsal  lesion  can 
be  excellently  treated  in  bed.  For  out-patient  work  the  spinal  board  and 
the  Phelps's  box  are  very  suitable,  because  they  are  the  easiest  in  transport. 
In  private  work,  where  expense  is  probably  not  so  important  a  consideration, 
one  frequently  advises  a  Bradford  or  a  Whitman  frame,  the  latter  when  the 
symptoms  are  urgent.  Gauvain's  back  -  door  and  wheelbarrow  splints 
require  a  considerable  amount  of  manipulation  and  attention,  and  for  that 
reason  one  uses  them  most  frequently  in  hospital  cases,  where  good  nursing 
facilities  are  always  at  hand. 

Lumfxir  Region. —Owing  to  the  tendency  which  lumbar  disease  has  to 
be  associated  with  psoas  spasm  and  flexion  of  the  thigh,  one  is  careful  in 
recommending  a  splint  for  this  region  to  choose  one  in  which  extension  can 
be  readily  applied.  Otherwise  one  is  guided  by  much  the  same  principles 
as  hold  good  in  the  dorsal  region  of  the  spine. 

Duration  of  Treatment  by  Recumbency.— It  is  essential  that 
recumbency  nuist  not  be  given  up  until  the  disease  in  the  vertebra;  has 
ceased  to  spread,  in  other  words,  until  the  process  of  cure  has  been  begun. 
In  point  of  time,  one  knows  that  this  never  occurs  in  less  than  one  year,  and 
in  all  probability  the  greater  part  of  two  years  has  elapsed  before  signs  of 
commencing    cure    are    apparent.     Complete    recumbency    must    therefore 

11 


162 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


continue  for  at  least  one  year,  or  preferably  for  a  year  and  a  half.  At  the 
end  of  that  period,  if  the  signs  are  favourable,  the  ambulatory  treatment 
may  be  begun.  There  are  certain  indications  which  one  assumes  as  favour- 
able to  the  commencement  of  the  ambulatory  stage.  1.  All  pains,  local  or 
referred,  must  have  disappeared.  2.  No  deformity  should  be  present, 
or  if  such  existed  before  the  treatment  was  begun,  the  degree  of  kyphosis 
should  not  have  increased.  3.  The  evening  temperature  must  have 
remained  normal  for  some  months.  4.  The  child  becomes  restless,  and 
is  perpetually  making  efforts  to  get  up.  5.  The  weight  has  increased. 
6.  On  examination  of  the  back,  it  is  found  that  the  situation  of  the  dis- 
ease is  firm  and  unyielding.     If  it  is  decided  that  the  conditions  favour 

the  commencement  of  the  ambu- 
latory stage,  it  must  be  remem- 
bered that  it  is  unwise  to  allow 
the  patient  immediately  to 
assume  the  vertical  position. 
He  has  been  so  long  in  the 
horizontal  position  that  any 
sudden  change  to  the  vertical 
is  associated  with  considerable 
changes  in  blood  pressure,  and  if 
these  facts  are  not  borne  in 
mind,  alarming  symptoms  may 
develop  when  the  patient  is- 
suddenly  set  upright.  He  should 
therefore  be  gradually  raised 
upon  his  couch  to  the  upright 
sitting  position,  later  he  is 
allowed  to  walk  about,  at  first 
for  a  few  minutes  only,  the  time 
being  gradually  extended.  He 
must  never  be  allowed  to  assume 
the  vertical  position  without  wearing  some  form  of  spinal  support. 

Gauvain  has  overcome  the  difficulty  of  gradual  elevation  by  using  a 
stand  in  which  the  patient  may  be  placed  in  any  position  or  angle.  His 
original  description  is  quoted  : 

The  essentials  in  this  stand  are  that  tfie  patient  at  will  may  occupy  any 
position,  either  horizontal  or  vertical,  or  at  any  intermediate  angle.  This  altera- 
tion is  very  simply  effected  by  merely  turning  a  handle,  which  governs  a  screw 
fitted  into  the  cogs  of  a  semicircular  piece  of  brass,  which  will  be  seen  attached 
to  the  under-surface  of  the  spinal  board.  The  patient  when  tilted  in  this  way 
should  have,  at  any  rate  in  the  case  of  an  adult  or  large  child,  additional  support 
to  that  given  by  the  jacket  before  described,  for  while  this  jacket  alone  will  hold 
him  firmly,  yet  without  other  assistance  it  may  cause  him  undue  and  unnecessary 
discomfort.  It  will  therefore  be  found  desirable  to  have  two  pieces  of  webbing 
passing  longitudinally  down  the  board  from  the  head  end  and  let  into  the  back 
of  the  spinal  jacket  on  either  side  of  the  spine.     These  pieces  are  continued  under 


Fig.  57. — Ganvain's  cippar.itus  for  the  gradual 
assumption  of  tlie  vertical  position. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  163 

the  crutch,  and  are  there  padded  with  a  small  pad  of  animal  wool  and  covered 
with  jaconet,  and  this  pad  is  so  adjusted  that  it  will  press  on  each  of  the  tuber 
ischii.  The  webbing  continued  from  the  crutch  passes  over  the  front  of  the 
patient,  and  is  strapped  to  the  board  on  each  side  at  about  the  level  of  the  nipple. 
This  simple  contrivance  will  effectually  and  comfortably  support  the  patient 
even  in  the  vertical  position,  and  will  not  in  any  way  bring  undue  pressure  to 
bear  upon  his  spinal  lesion  provided  he  has  in  the  first  place  been  so  placed  on 
his  board  that  the  spine  is  sufiiciently  hyper-extended.  In  many  cases  it  is  per- 
missible to  allow  the  patient  to  rest  on  a  seat,  which  can  be  suitably  adjusted 
to  the  spinal  board.  This  is  permissible  when  there  has  been  no  spasm  of  the 
psoas  muscle,  or  when  there  have  been  no  complications,  such  as  gluteal  abscesses. 
It  will  be  at  once  seen  that  when  the  patient  is  in  this  position  he  has  the  great 
advantage  of  seeing  surrounding  objects  with  ease,  and  when  a  suitable  book- 
rest  is  adjusted  to  the  board  he  can  read  and  feed  him.self  with  comfort  in  the 
natural  position.  Such  a  contrivance  will  be  found  of  the  very  greatest  service 
to  these  patients,  who  are  so  helpless  and  so  debarred  from  simple  pleasures  and 
conveniences,  and  it  will  be  of  particular  value  in  the  case  of  children,  who  can 
thereby  continue  their  education  within  reasonable  limits  without  in  any  way 
complicating  or  interfering  with  the  treatment  which  is  being  applied.  It  will 
be  noted  that  this  tilting  stand  is  mounted  on  wheels,  and  can  easily  be  wheeled 
out  of  the  ward  or  room  into  the  open  air,  and  in  fact  can  be  wheeled  anywhere 
as  easily  as  could  a  bath-chair,  and  the  delight  which  this  possibility  of  change 
of  scene  gives  to  the  child  is  of  value  and  assistance  in  the  treatment.  He  can. 
be  conveniently  and  expeditiously  removed  out  of  doors  and  attended  to  through- 
out the  day,  and  this  in  itself  is,  as  will  be  readily  seen,  of  the  greatest  value. 

B.  Ambulatory  Treatment. — This  term  is  applied  to  the  course  of 
treatment  wlicn  the  patient  i.s  allowed  to  go  about,  his  spinal  column  being 
supported  and  stiffened  by  some  type  of  apparatus.  The  various  forms  of 
appliance  are  described  as  spinal  supports  and  head  supports. 

Characteristics  of  efficient  Spirud  Supports. — It  is  a  matter  of  regret  that 
in  the  making  of  these  supports  instrument  dealers  too  often  neglect  the 
very  points  which  ensure  successful  treatment.  An  appliance  which  comes 
short  of  certain  necessities  is  a  useless  encumbrance.  A  serviceable  support 
must  fulfil  the  following  conditions  : 

(1)  As  its  principle  is  to  exert  a  considerable  amount  of  pressure  upon 
the  spinal  cokunn,  it  is  essential  that  there  shall  be  a  fixed  point  from  which 
this  pressure  can  be  exerted.  This  fixed  point  is  usually  obtained  by 
an  accurately  fitting  pelvic  band. 

(2)  The  pressure  brought  to  bear  up(jn  the  spine  should  be  exerted  along 
the  transverse  processes  of  each  side. 

(3)  The  support  must  be  of  such  a  kind  tluit  it  does  not  compress  the 
lateral  chest  wall,  and  so  intorfere  with  the  healthy  respiratory  movements. 

(1)  In  dorsal  and  in  lumbar  disease  the  posterior  pressure  on  the  spine 
must  bo  counterbalanced  by  support  given  to  the  chest  in  front.  If  this  is 
not  provided,  the  pressure  exerted  upon  the  spine  behind  is  simply  accom- 
modated for  by  a  compensatory  anterior  enlargement  of  the  chest  or 
abdomen. 

(5)  If  the  disease  is  situated  above  the  tenth  dorsal  vertebra  antl  below 
the  level  of  the  eighth,  the  support  must  extend  above  and  in  front  of  the 


164  TUBEECULOSIS  OF  THE  BONES  AND  JOINTS 

shoulders  ;    if  it  lies  above  the  level  of  the  eighth  dorsal  vertebra,  the  head 
and  neck  must  be  included  in  the  support. 

Indications  for  Ambulatory  Treatment. — Briefly  it  may  be  said  that 
ambulatory  treatment  is  indicated  when  the  active  stage  of  the  disease  is 
ended,  when  there  is  no  indication  of  a  further  extension  of  the  disease,  and 
when  there  is  a  reasonable  prospect  of  the  diseased  spine  becoming  com- 
pletely cured,  if  it  is  efficiently  immobilised. 

Spinal  Supports 

The  Plaster  Jacket. — One  has  no  hesitation  in  saying  that  a  properly 
applied  plaster  jacket  is  the  most  effective  immobiliser  of  the  spine  which 
we  possess. 

Advantages  and  Disadvantages. — Many  arguments  have  been  urged 
against  it  :  its  efficacy  has  been  doubted  ;  it  is  said  to  be  unsuitable 
for  children  ;  its  weight  has  been  condenmed  ;  it  is  said  that  if  it  is 
applied  sufficiently  accurately  to  be  of  any  real  value  it  must  of 
necessity  interfere  considerably  with  respiration  and  digestion  ;  and 
finally  it  has  been  objected  to  as  insanitary.  Most  if  not  all  of  these 
charges  are  groundless.  "When  properly  applied,  the  spine  can  have  no 
more  efficacious  support,  because  the  plaster  can  be  so  accurately 
moulded  to  the  spinal  outline.  Its  use  in  children  has  been  opposed, 
because  the  pelvis  is  said  to  be  so  insufficiently  developed  that  a  proper 
purchase  cannot  be  obtained.  As  a  matter  of  fact  the  jacket  can  be  fitted 
to  a  child's  pelvis  just  as  efficiently  as  to  that  of  an  adult.  The  weight 
depends  entirely  upon  the  amount  of  plaster  used  in  making  the  jacket.  As 
the  operator's  skill  increases,  the  amount  of  plaster  required  to  give  fixation 
is  lessened ;  and  when  the  support  is  completed,  its  weight  can  be  greatly 
reduced  by  cutting  out  anterior  and  lateral  windows.  By  the  removal  of 
windows  the  objection  of  imijeded  respiration  and  digestion  is  removed. 
The  argument  of  the  jacket  being  insanitary  has  some  foundation.  It 
should  not  therefore  be  employed  in  the  poorer  class  of  out-patients,  but 
rather  in  those  whose  cleanliness  can  be  trusted. 

Indications. — The  cases  which  one  considers  as  favourable  for  treatment 
are  those  which  have  reached  a  degree  of  cure  permitting  ambulatory 
methods,  which  are  physically  strong,  and  which  have  the  privileges  of  con- 
scientious parents  and  good  homes. 

The  situation  of  the  disease  matters  little.  It  is  of  course  easier  to  apply 
a  plaster  jacket  for  low  dorsal  disease  than  one  for  cervical  disease,  but 
both  can  be  applied  to  act  equally  well.  The  presence  of  a  sinus  or  of  an 
abscess  is  not  a  contra-indication,  if  it  is  possible  to  cut  a  window  in  the 
jacket  in  such  a  position  as  to  give  free  admission  to  the  part. 

Method  of  Af plication. — The  method  of  making  plaster  bandages  has 
been  detailed.  It  remains  to  describe  the  technique  observed  in  the  applica- 
tion of  a  plaster  jacket. 

Gauvain's  Method. — The  patient  has-been  educated  to  assume  the  vertical 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


165 


position  until  he  is  able  to  stand  upright  without  any  danger  of  syncope 
occurring.  The  skin  is  carefully  cleansed  and  powdered,  the  bowels  are 
thoroughly  emptied,  and  food  likely  to  cause  flatulence  is  avoided.  A  closely 
fitting  vest  is  applied  to  the  patient's  body,  and  over  the  epigastric  region, 
beneath  the  vest,  a  pad  of  cotton  wool  is  placed,  so  that  if  distention  should 
occur  before  a  window  is  cut  out  no  discomfort  will  ensue.  The  lower  part 
of  the  vest  is  pinned  in  the  perineum.  If  the  cervico-dorsal  or  cervical  spine 
is  diseased,  the  vest  is  carried  upwards  as  far  as  the  occiput,  and  this  is  best 
done  by  using  a  vest  with  a  specially  long  neck,  which  is  drawn  over  the  head 
and  pinned  above.  A  diagonal  window  is  cut  out  opposite  the  nose,  and 
when  the  window  is  stretched  the  patient  can  see  and  breathe. 

The  patient  is  now  ready  for  suspension.  A  bridle  specially  made  for 
.each  individual  case  is  fitted  to  his  head.  The 
bridle  is  made  by  tying  an  ordinary  knot  in  a 
2-inch  calico  bandage  4  feet  long.  The  knot  is 
tied  in  such  a  way  that  there  is  a  free  loop.  The 
knot  is  placed  immediately  above  the  right  ear. 
One  limb  of  the  bandage  is  now  passed  beneath 
the  chin  and  the  second  limb  beneath  the  occi- 
put, and  both  are  tied  above  the  left  ear.  One 
end  of  the  bandage  is  passed  through  the  loop 
left  from  the  knot  upon  the  right  side,  and  the 
free  ends  of  the  bandage  are  firmly  tied.  The 
patient  is  suspended  from  a  gallows  by  the 
bandage  passing  across  the  top  of  the  head. 
By  altering  the  situation  of  the  knots  the  posi- 
tion of  the  head  is  changed  ;  the  more  anterior 
the  knot  the  more  extended  does  the  head 
become,  the  more  posterior  the  knot  the  more 
flexed  the  head. 

The  patient  is  suspended  to  such  a  degree 
of  extension  that  the  heels  are  off  the  ground, 
and  he  rests  entirely  upon  his  toes.  He  acquires 
a  certain  amount  of  support  by  holding  adjust- 
able pegs  fixed  to  the  sides  of  the  gallows. 
The  bandages  are  now  applied,  those  6  inches  wide  are  employed,  and  each 
bandage  is  wrung  out  of  cold  water.  The  operator  stands  in  front  of  his 
patient  and  an  assistant  behind.  The  free  end  of  the  bandage  is  applied 
below  the  crest  of  the  ilium  upon  the  right  side,  and  the  roller  is  unwound, 
covering  in  the  body  from  below  upwards.  At  least  once  in  each  circuit 
the  bandage  is  pleated  by  doubling  it  backwards  in  its  course  for  about 
one  inch,  and  then  proceeding  as  before.  Pleating  has  a  double  advantage — 
it  allows  the  jacket  a  comfortable  degree  of  yield  before  it  actually  sets,  and 
after  a  pleat  is  made,  the  bandage  can  be  carried  in  any  desired  direction. 
No  reverse  nuist  be  made.  After  each  circuit  the  bandage  is  gently  r\il)l)ed 
into  the  turn  lying  imnicdiatcly  beiieatli.     When  the  patient's  trunk  has 


Flo, 


—Suspensory  sling  npplied 
in  preparation  for  the  application 
of  tliu  plaster  jacliet. 


166 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


been  efficiently  encircled,  and  usually  three  6-incli  bandages  are  sufficient 
for  the  purpose,  the  technique  of  moulding  to  the  jielvic  bones  is  proceeded 
with.  This  is  carried  out  very  carefully,  and  the  secret  of  the  success  of 
the  method  is  to  avoid  all  pressure  upon  the  bony  pelvis,  but  to  centre  one's 
pressure  upon  the  soft  parts  immediately  above.  When  this  is  complete 
the  shoulders  are  incorporated  in  the  bandage.  They  are  pressed  well  back, 
and  a  bandage  is  passed  backwards  and  forwards  above  them  until  sufficient 
support  has  been  gained.  The  cross  bandages  are  held  in  position  by 
circular  turns  passing  below  the  axilla. 


Fig.  59. — The  "Minerva"  plaster  juL-ket  applied. 


Fio.  60.— The  "  Mlii.  rva  "  plaster 
jacket  applied,  lateral  view. 


The  system  of  moulding  is  now  applied  above  and  below  the  clavicles. 
The  neck  is  encased  by  successive  turns  of  the  bandage,  and  in  each  circular 
turn  at  least  two  pleats  are  included.  The  bandage  passes  from  the  neck, 
around  the  head,  under  the  chin,  and  under  the  occiput.  It  is  carefully 
moulded  under  the  chin,  under  both  mastoid  processes,  and  beneath  the 
occiput.  When  the  jacket  has  hardened  sufficiently,  windows  are  marked 
out ;  they  are  not,  however,  cut  until  the  second  day  after  application  of  the 
plaster.  A  large  window  is  cut  out  in  front  to  allow  free  respiration  and 
digestion,  and  if  there  is  any  angulation  of  the  spine,  a  window  is  cut  out  over 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


167 


it.  The  plaster  is  cut  away  around  the  head,  below  each  ear,  and  in  its  lower 
part,  to  allow  free  flexion  of  the  thighs.  The  plaster  is  cut  with  a  small, 
strong  penknife,  the  blade  of  which  is  continually  moistened  with  water, 
and  when  the  various  windows  have  been  cut  and  edges  trimmed,  the  vest 
is  turned  back  over  the  plaster,  and  fastened  securely  around  by  a  layer  of 
plaster  cream.  The  whole  sur- 
face of  the  jacket  is  afterwards 
covered  with  a  thin  layer  of 
plaster  made  up  in  3  parts  of 
water  to  5  parts  of  plaster. 

When  the  jacket  extends  so 
high  as  to  be  below  the  jaw,  the 
mastoid,  and  the  occiput,  the 
name  "  Minerva  "  is  applied. 
It  has  the  disadvantage  that  it 
interferes  with  mastication,  and 
in  eating  the  patient  has  to 
keep  continually  throwing  his 
head  back.  To  overcome  this 
difficulty,  and  the  further  one 
that  it  interferes  with  the  de- 
velopment of  the  lower  jaw, 
Gauvain  introduced  the  type  of 
jacket  which  he  calls  "  the 
Fillet."  It  will  be  understood 
on  reference  to  the  illustration. 
While  the  head  portion  is 
moulded  carefully  to  the  mas- 
toids and  the  occiput,  the  an- 
terior portion  does  not  come 
into  contact  with  the  lower  jaw. 
Fixation  is  gained  instead  by 
carrying  a  narrow  band  of  the 
plaster  around  the  forehead  in  such  a  position  as  to  keep  the  head  extended. 

The  Hammock  Fmme  Method. — In  this  method  the  jacket  is  applied  with 
the  child  lying  prone  upon  a  strip  of  cloth,  the  cloth  being  attached  to  a  frame 
by  which  it  can  be  tightened  or  loosened  at  will.  The  cloth  or  hammock 
is  made  from  cotton  sheeting.  It  is  double  the  width  between  the  iliac 
spines,  and  it  is  some  inches  longer  than  the  child.  In  use  it  is  doubled, 
and  a  wide  hem  made  at  each  end.  The  frame  is  a  parallelogram  of  1-inch 
galvaTiised  iron  piping.  It  usually  measures  6  feet  by  2  feet,  and  it  is  fixed 
in  such  a  position  that  the  upper  end  is  (i  inches  higher  than  the  lower  one. 
At  the  upper  end  of  the  frame  there  is  a  transverse  iron  rod  attached  to  the 
upper  end  by  two  S  hooks.  At  the  lower  end  a  bar  stretches  across  the 
breadth  of  the  frame,  and  the  bar  can  be  revolved  by  turning  a  winch  handle 
at  tlu^  side.     A  ratchet  is  provided  to  control  the  amount  of  reverse  move- 


Fio.  61. — Tlie  "Fillet"  pListcr  jacket  aiiplieJ. 


168  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

ment  of  the  bar  ;    near  the  centre  is  a  second  bar,  similar  to  that  at  the 
upper  end. 

The  hammock  is  attaclied  to  the  frame  by  passing  the  two  transverse 
bars  through  the  hems  in  the  canvas.  The  upper  bar  is  fastened  to  the 
frame  by  its  screws,  the  lower  bar  is  connected  with  cords  to  the  ratchet  bar 
at  the  extreme  lower  end  of  the  frame,  and  by  manipulating  the  screw  handle 


Fig.  62. — The  liammock  frame  nietliod  of  applying  the  plaster  jacket. 

the  hammock  can  be  loosened  or  tightened  at  will.     The  child  is  placed  upon 
the  hammock  face  downwards,  and  the  screw  is  loosened  sufficiently  to 


Fio.  63. — Ridlou's  bridge  for  supporting  the  p.itieut  during  the  application 
of  ;i  plaster  jacket. 

produce  the  requisite  amount  of  lordosis.  The  arms  of  the  child  grasp  the 
top  bar  of  the  frame,  and  additional  support  is  given  by  broad  webbing 
straps  which  pass  across  beneath  the  upper  chest  and  the  knees. 

The  child's  trunk  is  clothed  in  stockingette,  and  padding  is  adjusted  to 
protect  the  sacrum,  the  crests  of  the  iha,  the  sternum,  the  claxacles,  and  the 
axillae.     Felt  pads  are  placed  upon  each  side  of  the  deformity.     The  plaster 


TUBERCULOUS  DISEASE  OF  THE  SPINE  169 

bandages  are  applied  below  and  to  include  tlie  point  of  deformity,  and  when 
the  plaster  has  set  the  hammock  is  further  loosened.  There  is  a  corresponding 
sagging  of  the  body,  but  as  the  lumbar  spine  is  fixed  in  the  plaster  which  has 
been  already  applied,  and  cannot  therefore  bend  further  back,  the  pressure 
is  exerted  upon  the  deformity,  which  improves  in  degree  and  may  even 
disappear.  In  this  corrected  position  the  application  of  the  jacket  is  com- 
pleted. A\Tien  the  jacket  has  hardened,  the  child  is  removed  from  the  frame 
by  cutting  the  hammock  cloth  above  and  below — the  cloth  of  course  being 
retained  as  part  of  the  jacket. 

The  advantages  of  this  method  are  the  comfort  of  the  child  during 
application,  the  absence  of  any  tendency  to  syncope,  and  the  correction  by 
hyperextension  which  can  be  obtained. 

The  Goldthicait  Method. — Goldthwait  uses  a  frame  very  similar  to  that 
employed  in  the  hammock  frame  method,  but  instead  of  the  patient  being 
prone  he  lies  on  his  back.  The  frame  is,  as  before,  a  gas-pipe  frame  measur- 
ing 6  feet  by  2  feet.  Suspended  from  the  frame  there  is  a  cross  bar  from 
the  centre  of  which  rises  a  vertical  bar,  forked  at  the  top  and  extending 
upwards  to  a  level  with  the  frame.  '  The  position  of  the  cross  bar  can  be 
altered  at  will,  as  it  is  suspended  from  the  frame.  A  simple  transverse  bar 
rests  on  the  frame  lower  down,  the  distance  between  the  two  usually  being 
about  16  inches.  Upon  the  vertical  fork  above  and  the  transverse  bar  below 
rest  two  malleable  steel  bars  about  18  inches  long.  They  are  fixed  in  grooves 
about  1  inch  apart,  and  they  are  moulded  to  conform  with  the  curve  of 
the  lumbar  spine.  The  patient  is  clothed  in  a  vest  of  stockingette,  and  laid 
upon  the  parallel  steels,  which  are  specially  padded  with  thick  felt. 

When  the  patient  is  in  position  the  upper  ends  of  the  bars  project  one 
inch  beyond  the  deformity,  while  the  buttocks  lie  opposite  the  lower  cross 
bar.  The  legs  are  supported  by  bands  of  webbing,  which  pass  beneath 
them  and  can  be  tightened  at  will.  At  first  the  head  is  supported  by  the 
operator's  hand,  and  allowed  to  sag  until  the  spine  is  sufficiently  hyper- 
extended.  The  head  is  then  supported  by  a  broad  band  of  webbing,  and  the 
plaster  jacket  is  applied  with  the  steel  bars  inside  it.  After  setting,  the 
patient  is  lifted  off  the  frame  and  the  bars  slipped  out.  The  jacket  is 
trimmed  in  the  usual  way. 

Bracl-elCs  Method. — Brackett  uses  a  frame  in  which  the  patient  lies  on 
his  back.  The  patient  is  supported  at  the  kyphosis  by  two  short  metal  plates 
which  impinge  one  on  each  side  of  the  middle  line.  These  plates  are  padded 
with  felt,  and  they  can  be  raised  or  lowered  at  j)leasure  by  a  Y-shaped  support. 
By  elevating  the  plates  the  deformity  is  gradually  corrected.  When  the 
jacket  is  applied  the  plates  remain  inside  it.  The  head  is  supported  upon  a 
series  of  parallel  transverse  bands  which  can  be  tightened  or  loosened  at 
will,  while  the  feet  rest  upon  a  board. 

Lovett's  Method. — Lovett  also  employs  a  frame.  The  patient  lies  on  his 
face  on  two  broad  straps  of  webbing,  with  one  cross  strap  at  the  trochanters, 
and  one  at  the  level  of  the  forehead.  The  upper  part  of  the  frame  is  made 
double   and  hinged  so  that  it  can  be  raised  at  will.     The  first  part  of  the 


170  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

jacket  is  put  on  below  and  up  to  the  level  of  the  deformity.  It  is  applied 
with  a  straight  lumbar  spine,  and  this  is  secured  by  having  the  patient's 
body  resting  upon  the  frame  straps  while  his  legs  hang  down.  When  the 
first  half  of  the  jacket  has  hardened,  a  thickly  padded  webbing  strap  is  tied 
across  the  child's  back  opposite  the  deformity.  The  hinged  front  half  of 
the  frame  is  raised,  and  a  corrective  pressure  is  exercised  by  the  webbing 
upon  the  kyphosis.  In  this  position  the  application  of  the  jacket  is  com- 
pleted. 


Fig.  64. — A  modification  of  the  Brackett  apparatus  for  applying  a  plaster  jai;ket. 

Metal  Braces 

The  Taylor  Brace.— In  1863  C.  F.  Taylor  published  a  description  of  a 
brace  which  was  intended  to  oppose  forward  movement  of  the  spine.  With 
certain  minor  modifications  this  splint  is  still  largely  used.  The  brace  is 
made  of  steel,  and  it  consists  of  two  uprights,  a  base,  two  shoulder-pieces, 
and  one  or  two  cross  bars.  The  uprights  are  two  vertical  bars  of  malleable 
steel,  -^  inch  thick  and  ^  inch  wide,  which  lie  one  upon  each  side 
of  the  middle  line  over  the  transverse  processes.  They  are  curved  to  fit 
the  outline  of  the  spine  with  the  patient  lying  down,  and  in  length  they 
extend  from  the  seventh  cervical  spine  to  1  inch  below  the  posterior- 
superior  spine  of  the  ilium.  The  lower  ends  of  the  uprights  must  pass 
between  the  posterior-superior  spines,  and  yet  leave  an  interval  of  |- 
inch.  If  the  child  is  so  small  that  this  is  impossible,  the  uprights  must 
then  end  at  the  horizontal  part  of  the  brace.  Opposite  the  deformity 
in  the  spine,  each  upright  has  attached  to  it  a  thin  steel  plate  ^ 
inch  wider  than  the  upright,  and  curved  to  fit  the  bac'K  from  above, 
downwards  and  laterally.  These  plates  are  made  of  spring  steel  No.  22 
gauge.  They  should  be  perforated  around  the  free  border  to  allow  a  pad 
to  be  stitched  in  place,  and  if  they  are  intended  to  exert  special  pressure 
upon  the  spine,  they  are  carried  forward  some  distance  in  front  of  the  upright. 
The  bottom  piece  or  base  may  vary  in  shape  ;  usually  it  takes  that  of  an 
inverted  U .     The  transverse  portion  crosses  the  lower  part  of  the  back,  above 

/ 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


171 


the  sacrum,  and  to  it  the  lower  ends  of  the  uprights  are  attached.  The 
inverted  Hmbs  extend  downwards  on  each  side,  two  finger-breadths  within 
the  inner  side  of  the  trochanter,  and  end  above  the  ischial  tuberosities,  so 
that  they  do  not  interfere  with  sitting.  Each  free  end  is  provided  with  a 
circular  leather-covered  pad.  The  shoulder-pieces  are  separate  pieces, 
each  7i  inch  wide  and  ^^  of  an  inch  thick,  attached  behind  by 
rivets  to  the  upper  ends  of  the  uprights.  They  are  fir.st  bent  outwards 
on  the  flat  at  an  angle  of  45  degrees,  and  then  they  are  bent  over  so  as 
to  conform  to  the  outline  of  the  root  of  the  neck.  In  front  they  end  at  the 
edge  of  the  trapezius  muscle.  The  cross  bars  are  usually  two  in  number  ; 
the  upper  one  is  attached  just  below  the  pos- 
terior border  of  the  axilla,  the  second  one 
lower  down.  They  are  ^  inch  wide  and  ^^ 
inch  thick,  they  are  a  little  shorter  than  the 
breadth  of  the  trunk,  and  they  are  fastened 
by  rivets  to  the  posterior  surface  of  the  up- 
rights. For  fastening  the  brace  to  the  body 
buckles  are  used.  These  are  1  inch  wide,  and 
they  are  secured  by  copper  rivets.  Buckles 
are  fastened  to  each  of  the  tips  of  the  D, 
one  to  each  corner,  and  one  to  the  end  of 
each  cross  bar.  To  the  extremity  of  the 
shoulder-piece  a  webbing  strap  1  inch  wide  is 
riveted.  The  front  of  the  body  is  covered 
with  an  apron  of  stout  drilling  or  canvas. 
In  width  it  extends  from  one  posterior  axil- 
lary line  to  the  other,  ending  above  at  the 
axilla  and  below  at  the  symphysis  pubis. 
The  corners  of  the  jacket  are  cut  away  so 
that  they  do  not  interfere  with  flexion  of  the 
thighs  or  movement  of  the  pectorals.  If  the 
apron  is  stiffened  at  the  sides  by  bones  there 
is  less  liability  to  crinkling, 
hemmed,  and  to  them,  webbing  straps  are 
fastened  which  are  attached  to  the  buckles  on 

the  brace.  Webbing  straps  are  fastened  one  on  each  side  about  an  inch 
above  the  lower  end  of  the  jacket.  They  pass  across  the  perineum,  and  are 
attached  to  the  buckles  at  tiie  tips  of  the  D-shaped  base.  In  this  way  the 
tendency  of  the  brace  to  slip  upwards  is  prevented. 

If  in  association  with  Pott's  disease  the  shoulders  are  dLsplacod 
forwards,  it  becomes  necessary  to  attach  a  Taylor  chest-piece  to  the 
ordinary  brace.  This  consists  of  two  triangular  pads  of  hard  rubber,  made 
to  fit  into  the  chest  wall  beneath  the  clavicles,  and  joined  to  one  anotlier 
by  a  jointed  bar  of  iron,  which  can  be  shortened  or  extended  at  will.  The 
pads  are  attached  above  by  straps  to  the  shoulder-pieces  and  below  to  the 
extremities  of  tin-  upper  cross  bar.     When  the  caries  is  situated  higher  than 


The  edffeS  are  ^""'"  ^^' — Antero-posterior  braco  fittoi 
with  the  Taylor  ring.  A  case  of 
upiier  dorsal  Pott's  disease. 


172  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

the  seventh  dorsal  vertebra,  a  Taylor  head  support  is  added  to  the  brace. 
This  is  described  later. 

AVhitman  recommends  that  if  there  is  no  deformity  when  the  brace  is 
applied,  the  uprights  ought  to  follow  exactly  the  spinal  outline.  But  if 
there  is  an  existing  deformity,  the  uprights  should  be  made  soiiiewhat 
straighter  than  the  curve  of  the  kyphosis,  so  that  a  corrective  pressure  is 
exerted. 

The  brace  has  many  advantages  to  recommend  it :  it  acts  as  a  most 
efficient  spine  immobiliser  and  it  is  light.  As  the  child  grows  the  brace  can  be 
easily  altered  to  suit  the  requirements  of  increasing  girth  and  height.  The 
objections  which  have  been  urged  against  it  are  few  and  unimportant.  It 
is  said  to  be  uncomfortable,  but  the  discomfort  quickly  lessens  and  eventually 
is  unnoticed.  Pressure  sores  are  said  to  have  been  produced,  but  with 
care  and  attention  to  cleanliness  they  should  never  occur.  Perhaps  the 
only  real  objection  is  the  difficulty  which  there  is  in  obtaining  an  accurately 
fitting  brace.  The  apparatus  requires  to  be  made  with  great  care,  as  its 
efficacy  entirely  depends  on  its  correct  fit.  It  ought  to  be  made  directly 
under  the  surgeon's  supervision  and  guidance. 

Schapp's  Brace. ^ — Schapp  criticises  the  types  of  spinal  support,  and 
describes  a  modification  of  the  Taylor  brace  which  is  worth  attention. 
There  is  a  flat  steel  band,  which  crosses  the  abdomen  as  low  as  possible 
without  being  displaced  by  the  thighs  when  the  patient  sits,  and  extends 
closely  around  the  sides  of  the  pelvis  and  downwards  for  2  or  3  inches.  It 
is  then  connected  with  the  horns  of  a  posterior  hip  band  by  straps.  The 
pelvis  is  actually  clamped  between  the  bands.  The  anterior-superior  spines 
are  protected  by  pads  of  kersey  and  leather,  and  the  middle  portion  of  the 
front  band  is  arched  forwards,  so  that  when  the  patient  is  supine  there  is  a 
space  behind  it  of  1|  inches  or  more.  This  will  be  filled  by  the  abdomen 
when  the  patient  stands.  At  the  location  of  the  anterior-superior  spines, 
flat  uprights  are  riveted  at  right  angles  ;  they  reach  nearly  to  the  top  of  the 
chest,  and  at  the  level  of  the  axillae  are  crossed  by  a  flat  band  extending 
jound  the  sides  of  the  chest  and  nearly  meeting. 

Davies'  Quadrilateral  Brace. — Taylor's  brace,  while  it  prevents  antero- 
posterior movement  of  the  spine,  does  not  prohibit  a  certain  degree  of  lateral 
movement.  Davies'  brace  was  designed  to  combine  the  action  of  a  back 
brace  with  that  of  a  side  support.  It  consists  of  a  base  or  pelvic  band,  two 
uprights,  a  top  bar,  and  a  pad  plate  bar.  The  pelvic  band  is  made  of  No. 
15  gauge  cast-sheet  steel.  It  is  moulded  to  fit  the  back  just  above  the 
trochanters,  and  in  front  it  ends  behind  and  slightly  below  the  anterior- 
superior  spines.  Its  ends  are  usually  joined  in  front  by  a  strap  of  webbing. 
The  uprights  are  made  of  No.  12  gauge  flat  steel.  They  are  half  an  inch  wide, 
and  they  are  riveted  to  the  pelvic  band,  one  on  each  side,  about  one  inch 
beyond  the  posterior-superior  spines.  They  end  a  finger-breadth  above  the 
spines  of  the  scapulae,  they  follow  the  curves  of  the  flanks,  and  when  the 
shoulder-straps  are  tightened  they  exert  most  pressure  upon  the  posterior 

I  Schapp,  Medical  Record,  Sept.  9,  1905. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


173 


surfaces  of  the  scapulae.  The  top  bar  passes  across  the  upper  end  of  the 
chest.  In  length  it  is  equal  to  the  distance  between  the  glenoid  cavities, 
when  the  shoulders  are  pressed  back.  Its  ends  are  bent  downwards  to  a 
right  angle,  and  they  are  riveted  to  the  upper  extremities  of  the  uprights. 
The  pad  plate  bar  is  a  horizontal  bar  of  half-inch  flat  steel,  No.  14  gauge, 
which  is  fastened  to  the  uprights  by  screws  opposite  the  kyphosis.  At  its 
centre  the  bar  is  bent  into  a  semicircle,  convex  backwards.  In  order  to 
avoid  pressure  upon  the 
spinous  processes,  and 
just  before  the  bend 
begins  upon  each  side, 
pad  plates  are  attached. 
These  pad  plates  are 
made  of  No.  18  gauge 
steel,  they  measure  ^ 
inch  by  3i  inches,  they 
are  fixed  with  the  long 
axes  vertical,  so  as  to 
press  directly  upon  the 
transverse  processes. 
The  pad  plate  bar  is  not 
'  fastened  with  rivets,  but 
with  slots  and  adjust- 
able screws,  so  that  the 
position  of  the  pressure 
of  the  pads  can  be 
altered  at  will.  The 
front  of  the  body  is 
covered  with  an  apron 
of  soft  leather  ^g  to  | 
of  an  inch  in  thickness. 
It  extends  from  the 
level  of  the  ensiform 
cartilage  to  the  sym- 
physis pubis  in  the 
middle  line,  and  1  inch 


F[a.  66. — Daviea'  quadrilateral  brace. 


below  the  anterior-superior  spines  laterally.  Webbing  straps  from  the 
apron  are  fastened  to  buckles  on  the  brace.  These  buckles  are  attached  at 
each  upper  corner — three  at  intervals  along  the  sides  of  the  uprights,  and  one 
at  each  end  of  the  pelvic  band.  The  special  head  support  for  attachment 
to  this  brace  is  described  later. 

Thornton's  Back  Brace. — This  brace  is  most  suitable  for  use  in  Pott's 
disease  of  tlie  lower  dorsal  and  dorso-hunbar  spine.  TIic  advantages  claimed 
for  it  are  those  of  secure  fixation  and  tiie  encouragement  of  free  chest  and 
lung  expansion.  It  is  composed  of  a  base-piece,  two  uprights  carrying  pad 
plates,  cross  bars,  and  a  shoulder-piece.     The  base-piece  is  shaped  like  a 


174 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


widely  separated  V.  It  covers  most  of  the  sacrum,  and  laterally  the  limbs 
extend  outwards  just  below  the  iliac  crests  to  a  point  behind  and  below 
the  anterior-superior  spines.     The  uprights  are  placed  in  exactly  the  same 

position  as  in  a  Taylor  brace,  and 
opposite  the  deformity  pad  plates 
are  used.  The  lower  cross  bar  is 
attached  just  above  the  iliac  crests, 
and  it  is  moulded  to  the  curves  of 
the  loin.  The  upper  cross  bar  is 
placed  below  the  tips  of  the  scapulae. 
The  uprights  are  riveted  above  to  a 
steel  plate,  V-shaped.  The  size  at 
the  apex  is  equal  to  the  distance 
between  the  uprights,  while  above 
the  limbs  are  3  or  4  inches  apart. 
At  the  extremities  of  this  plate 
L-shaped  steel  pieces  are  loosely 
riveted.  The  vertical  limb  of  the 
L  runs  outwards  to  the  glenoid 
cavity,  then  there  is  the  angle,  and 
the  horizontal  limb  passes  vertically 
downwards  to  the  lower  fold  of  the 
axilla  and  curves  slightly  forwards. 
From  the  angle  of  the  L  to  the  end 
in  the  axilla  a  buckling  strap  passes, 
and  in  front  of  the  body  there  is  an 
apron  of  leather  or  cloth,  extending 
mesially  from  the  nipple  to  the 
symphysis  and  laterally  from  the 
eighth  rib  in  the  mid-axillary  line  to 
just  below  the  anterior-superior  iliac 
spine.     The  apron  is  attached  to  the  brace  by  straps  and  buckles. 

The  Flexible  Steel  Brace. — In  the  convalescent  stages  of  Pott's  disease, 
when  the  spine  requires  only  a  slight  degree  of  protection,  the  essentials 
are  supplied  by  a  flexible  steel  brace.  A  horizontal  pelvic  band  encircles 
the  posterior  part  of  the  pelvis,  and  ends  on  each  side  at  a  point  1  inch 
behind  the  antero-superior  spine  of  the  ilium.  This  band  is  carefully  figured 
to  a  paper  pattern.  It  is  1^-  inches  wide,  and  it  is  cut  from  No.  16  gauge 
sheet-steel.  The  uprights  are  fastened  to  the  pelvic  band,  li  inches  apart. 
They  pass  upwards  on  each  side  of  the  middle  line  until  they  reach  the  first 
dorsal  vertebra,  when  they  are  1  inch  apart.  From  this  point  they  bend 
outwards  at  an  angle  of  45  degrees,  extending  as  shoulder-pieces  for  2 
inches.  A  cross  bar  |  inch  wide  is  riveted  to  the  uprights  1  inch  below 
the  posterior  axillary  folds.  It  extends  upon  each  side  to  within  1  inch  of 
the  width  of  the  body.  Straps  connect  the  tips  of  the  shoulder-pieces  to  the 
ends  of  the  cross  bar,  the  straps  arching  across  the  front  of  the  shoulders. 


Fig.  67. — Thornton's  b.ack  brace  for  Pott's  disease 


TUBERCULOUS  DISEASE  OF  THE  SPINE  175 

The  ends  of  the  pelvic  band  are  united  in  front  with  strap  and  buckle,  and 
it  is  a  further  benefit  to  have  a  broad  abdominal  belt,  divided  into  two  halves, 
each  attached  to  the  upright  behind  and  the  half  of  the  opposite  side  in  front. 
Tubby's  Spinal  Support. — This  is  an  apparatus  which  acts  on  the 
principle  of  a  Taylor  brace.  It  affords  considerable  lateral  and  antero- 
posterior fixation.     The  original  description  is  as  follows  : 

The  first  e.sseiitial  is  a  good  base  of  support,  which  is  afforded  by  a  well- 
fitting  and  accurately  adjusted  pelvic  band,  so  arranged  that  it  can  be  opened  iu 
front.  The  band  has  fixed  to  it  two  pieces  of  steel,  each  arching  over  on  either 
side  from  just  in  front  of  the  anterior-superior  to  the  posterior-superior  spines. 
At  the  centre  of  the  pelvic  band,  posteriorly,  a  double  steel  upright  is  fixed,  which 
reaches  above  to  a  little  below  the  level  of  the  line  joining  the  spines  of  the 
scapulae,  thence  two  transverse  steel  bands  pass  outwards  to  beueath  the  axillse. 
In  order  to  ensure  sufficient  rigidity,  two  lateral  steel  uprights  pass  from  the  pelvic 
band,  and  are  joined  to  the  upper  transverse  bands  just  below  the  axillae,  and 
end  in  horned  and  pear-shaped  extremities.  They  lie  between  the  coracoid 
processes  and  the  heads  of  the  humeri.  The  utility  of  the  apparatus  depends 
upon  an  accurate  fitting,  which  is  made  while  the  patient  is  suspended,  and 
when  it  is  removed  at  night  the  patient  ought  to  be  lying  down.  It  is  replaced 
in  the  morning  before  the  patient  rises  from  the  horizontal  position.  The 
posterior  uprights  lie  exactly  in  the  lines  of  the  transverse  processes,  and  there 
must  be  no  pressure  on  the  transverse  processes  nor  on  the  ribs.  The  uprights 
are  made  so  that  they  first  fall  short  of  exactly  following  the  curves  of  the 
vertebral  column,  thus  exercising  a  lever-like  action,  as  in  the  Taylor  brace. 
When  the  posterior  deformity  is  small  and  the  vertebrse  are  not  fully  ankylosed, 
advancing  plates  may  be  fitted  to  the  uprights,  so  as  to  bring  moderate  pressure 
to  bear  on  the  transverse  processes  at  the  projection.  The  main  object  of  the 
apparatus  is  to  exert  antero-posterior  leverage  on  the  spinal  curvature,  exactlv 
in  the  same  way  as  if  one  stands  behind  a  healthy  person  and  puts  the  arms  and 
hands  beneath  the  subject's  axillae  and  exerts  backward  traction.  The  effect 
is  that  the  patient  is  absolutely  prevented  from  flexing  his  spine.  To  cover  the 
chest  and  abdomen,  stay  material  with  lacing  down  the  front  is  used,  and 
further,  if  the  disease  is  above  the  eighth  dorsal  vertebra,  a  head  support  with 
a  chin  piece  is  added.^ 

Leather  Jackets. — In  the  later  stages  of  convalescence  leather  jackets 
may  be  used.  A  piaster  cast  is  first  taken  of  the  chest  and  spine.  If  an  old 
jacket  is  available,  a  cast  may  be  obtained  by  blocking  up  its  apertures  with 
brown  paper  and  filling  the  interior  with  plaster.  If  this  is  not  possible 
a  negative  is  taken  of  the  chest  with  piaster  bandages  (see  later)  and  a 
positive  made.  By  adding  an  additional  thin  layer  of  plaster  the  size  of 
the  cast  is  slightly  and  evenly  incrca.sed.  This  is  necessary  as  the  leather 
contracts  during  its  application  and  drying,  and  what  may  appear  to  be  a 
well-fitting  jacket  is  actually  too  small.  Oak-tanned  English  leather  is 
used.  It  is  soaked  in  water  niitil  thoroughly  soft,  and  then  stretched  U])on 
the  cast.  It  is  made  to  conform  to  every  outline  and  hollow.  One  edge  is 
secured  to  the  cast  by  tacks,  and  the  other  edge  secured  when  it  is  properly 
fitted.     Sometimes  it  may  be  adapted   by  tightly  and   evenly  winding  a 

'  'I'lilpliy,  loc.  Klip.  cil.  viil.  ii.  ]).   KU. 


176 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


small  rope  round  the  cast  with  the  leather  in  position,  or  it  may  be  tightly 
bandaged  on  with  webbing.  The  leather  is  allowed  to  harden  at  ordinary 
temperature,  or  it  may  be  baked  at  a  temperature  not  exceeding  120°  P. 
When  it  is  thoroughly  dry,  hot  bayberry  wax  is  painted  on  until  no  more  is 
absorbed.  The  wax  has  a  double  advantage — it  bears  a  dull  non-absorbent 
surface  which  is  pleasant  to  the  touch,  and  if  any  portion  of  the  jacket 
requires  to  be  remodelled,  this  can  easily  be  done  by  heating  the  part.  The 
wax  melts,  the  leather  softens,  and  the  part  may  be  remodelled  as  desired. 
The  jacket  may  be  painted  with  three  or  four  coats  of  shellac.  This  increases 
its  durability.  The  free  edges  of  the  jacket  are  bound  with  strips  of  soft 
sheepskin,  and  if  any  portion  of  the  border  sticks  inwards  and  is  uncom- 


FlG.  6S. — Thomas  cuirass  showing 
the  framework  before  it  is 
covereil  with  leather. 


I. — The  complete  Thomas 
cuirass. 


fortable,  it  may  be  softened  by  scoring  it  with  a  number  of  parallel  nicks, 
and  rubbing  it  until  it  yields. 

Celluloid  Jackets. — Jackets  made  of  celluloid  have  many  advantages. 
They  are  comparatively  cheaply  made  ;  as  they  are  made  upon  a  cast  their 
fit  can  be  guaranteed  ;  they  combine  lightness  and  a  certain  degree  of 
elasticity  with  considerable  strength. 

A  plaster  cast  is  first  taken  of  the  patient's  body.  For  this  purpose  the 
patient  is  held  in  a  position  of  slight  extension,  most  conveniently  by  being 
suspended  from  a  gallows.  In  this  position  the  part  to  be  cast  is  thordughly 
anointed  with  vaseline  or  warm  olive  oil,  and,  beginning  below,  the  trunk  is 
encased  with  a  plaster  bandage  ;  the  first  turns  of  the  bandage  encircle 
the  trunk  below  the  iliac  crests  and  at  the  level  of  the  symphysis  pubis. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


177 


It  then  gradually  rises,  and  the  shoulders  are  included  by  cross  turns  passing 
from  chest  to  back  and  vice  versa.  If  the  neck  is  to  be  included  the  case 
extends  upwards  as  far  as  the  occiput.  As  the  plaster  is  drying  it  is  carefully 
moulded  to  certain  body  outlines  :  below  the  iliac  crests,  above  the  sym- 
physis pubis,  along  the  length  of  the  spine,  and  over  the  outlines  of  the 
scapulae,  above  and  below  the  clavicles,  and,  m  a  high  case,  around  the  occiput 
and  the  mastoid  processes.     When  the  plaster  has  sufficiently  set,  the  casting 


Fui.  70. — III  making  tliu  cast  the  ri'iiioviil 
of  tlie  itlastL-rcitst;  from  the  Ijody  is 
fiicilitateil  if  a  atrip  of  boraciu  lint  ia 
laid  on  tlie  sije  of  tlie  body  as  is 
shown  in  the  illustration. 


F[i;.  71. — The  plaster  "negative."  The 
lateral  iueision,  which  was  made  to 
enable  the  negative  to  be  removed  from 
the  body,  is  repaired  by  an  ensheathiug 
plaster  bandage. 


is  removed  from  the  body  by  slitting  it  up  one  side  of  the  body,  above  the 
shoulders  and  along  the  side  of  the  neck.  In  removing  the  casting  it  may 
sometimes  be  difficult  to  avoid  cutting  the  patient's  skin.  The  risk  is 
obviated  by  laying  a  narrow  strip  of  boracic  lint  upon  the  skin  beneath 
the  plaster  and  along  the  line  of  removal.  The  shape  is  carefully  restored. 
It  is  kept  in  proper  position  with  a  few  turns  of  a  plaster  bandage,  and  the 
jacket  is  allowed  to  harden.  The  positive  is  now  made.  The  interior  of 
the  negative  is  carefully  oiled.  It  is  placed  upright  in  a  box  of  sand  so  that 
its  lower  outlet  is  closed,  and  the  arm  openings  are  obliterated  by  a  few  turns 

12 


178 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


of  a  plaster  bandage.  A  quantity  of  the  ordinary  commercial  plaster  is 
made  up,  using  5  parts  of  water  to  3  parts  of  dry  plaster,  and  the  interior  of 
the  mould  filled  wath  it.  As  the  plaster  is  hardening,  a  stout  wooden  rod 
is  thrust  into  it  to  form  a  useful  handle,  projecting  above  the  cast.  As  soon 
as  the  plaster  is  hard  the  negative  is  removed,  and  the  work  of  modelling 
the  positive  is  begun.  With  a  strong  penknife  it  is  sculptured  so  as  to  ac- 
centuate the  depressions  from  which  the  jacket  will  take  its  purchase.  This 
manipulation  requires  to  be  carried  out  with  great  judgment  and  care.  The 
whole  of  the  cast  is  now  covered  with  a  thin  additional  layer  of  plaster  to 


Fig.  72. — The  completed  "positive." 


Fig.  73. — The  "  positive  "  covered  with  the 
original  layers  of  "  stockingette  "  aiid 
gauze. 


increase  uniformly  the  bulk  of  the  cast,  and  so  ensure  the  better  fit  of  the 
jacket.  Over  the  cast  a  vest  of  cotton  or  stockingette  is  drawn.  It  must 
fit  the  cast  outline  exactly,  and  therefore  it  ought  to  be  in  actual  size  some- 
what smaller.  Its  fit  is  made  accurate  by  a  few  adjusting  stitches,  and  by 
bands  of  narrow  tape  that  stretch  across  uneven  places  and  are  stitched 
upon  the  under  surface. 

The  celluloid  solution  has  meantime  been  prepared  by  dissolving  celluloid 
cuttings  in  a  solution  of  acetone.  To  render  the  mixture  non-inflammable, 
to  every  150  oz.  of  celluloid  dissolved  in  acetone  5  oz.  of  a  solution  of  calcium 
chloride  in  water  is  added,  the  strength  of  the  calcium  chloride  solution  being 
in  the  proportion  of  3  oz.  of  calcium  chloride  to  2  oz.  of  water  (Gauvain). 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


179 


This  mixture  is  painted  on  to  tlie  vest  with  an  ordinary  stiff  brush,  and 
thoroughly  worked  in.  As  each  coat  dries,  a  successive  one  is  painted  on 
until  three  or  four  layers  have  been  applied.  When  this  original  application 
has  dried,  and  it  requires  about  four  hours  to  do  so,  a  layer  of  unstiffened 
book-muslin  is  applied  to  the  cast  in  two  antero-posterior  halves,  over- 
lapping at  the  sides.  The  layer  of  muslin  is  impregnated  with  celluloid  and 
allowed  to  dry.  Successive  layers 
are  thus  applied  until  a  sufficient 
strength  has  been  obtained. 
Anything  from  ten  to  twenty 
layers  may  be  required.  • 

Portions  of  the  jacket  which 
are  likely  to  bear  the  greatest 
strain  are  specially  strengthened 
by  small  additional  layers,  and 
the  jacket  is  finished  by  the  addi- 
tion of  several  coats  of  celluloid. 
The  jacket  is  removed  from  the 
cast  usually  by  cutting  it  an- 
teriorly up  the  middle  line.  It 
is  now  placed  on  the  patient  and 
carefully  fitted.  The  edges  are 
trimmed,  and  MTith  a  pencil  the 
windows  to  be  cutout  are  marked. 
A  large  anterior  window  is  the 
most  essential.  The  interior  of 
the  jacket  is  lined  with  wash 
leather,  and  the  edges  are  bound 
with  strips  of  similar  material. 
Along  opposite  sides  of  the  middle 
line  a  number  of  lacing  hooks  are 
inserted. 

The  lower  part  of  the  jacket 
is  sometimes  complained  of  as 
giving  rise  to  pressure.  In  front 
it  ought  to  extend  just  to  the 
upper  border  of  the  j)ubis  ;  later- 
ally it  extends  over  the  centre 
of  Poupart's  ligament,  and  just  above  both  great  trochanters ;  posteriorly 
it  passes  across  the  centre  of  the  sacrum  ;  above  it  ought  to  be  out  away 
freely  beneath  the  arms. 

This  form  of  jacket  will  bi'  found  a  most  excellent  splint  during  con- 
valcHCpnfo. 

The  Knight  Spinal  Brace.  In  the  final  stage  of  treatment,  when 
convalescence  is  well  advanced  and  cure  is  practically  complete,  it  may  be  of 
advantage  to  supply  the  patient  with  a  brace  which  gives  support  and  a 

12  a 


Fia.  74. 


-The  lli'.\il>le  conv.ile.sLi'iit  liack  brace  for 
Pott's  disease. 


180 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


slight  amount  of  fixation.  An  ordinary  long  corset,  strengthened  by  steel 
bars  along  the  spine,  may  be  used,  or  a  Knight  spinal  brace.  The  structure 
of  the  latter  is  best  understood  by  reference  to  Fig.  74.  A  pelvic  band  of 
light  steel  passes  round  the  pelvis,  below  the  crest  of  the  ilium,  and  ends 
below  and  behind  the  anterior-superior  spine  of  each  side.  Two  vertical 
steel  bands  1  inch  wide  extend  upwards  from  the  jjelvic  band  upon 
each  side  of  the  spine  to  the  level  of  the  sixth  dorsal  vertebra.  Their  upper 
ends  are  connected  by  a  costal  band,  which  from  the  level  of  the  sixth  dorsal 
vertebra  passes  obhquely  downwards  into  the  centre  of  the  axilla.  It  ends  on 
each  side  at  the  anterior  axillary  line.  The  termination  of  the  costal  and 
pelvic  bands  are  united  by  vertical  bands  on  each  side.  There  is  a  single 
cross-bar  at  the  centre  of  the  posterior  part  of  the  brace.  Support  is  given 
in  front  by  a  lacing  corset.  Other  varieties  of  jacket  have  been  made  from 
poroplaster,  aluminium,  papier  mache,  and  silicate  of  potash.  Each  of  these 
substances  possess  disadvantages,  which  render  them  inferior  to  the  materials 
already  described. 

Head  Supports 

.  For  cervical  disease,  cervico-dorsal  disease,  and  dorsal  disease  occurring 
above  the  level  of  the  seventh  dorsal  vertebra,  certain  modifications  have 
to  be  added  to  the  brace  or  jacket  to  support  the  head.  The  more  important 
of  these  various  supports  are  now  described. 

The  Jury-mast.  —  The  jury-mast  should  be 
made  of  tempered  steel.  Its  base  is  composed  of 
a  flat  bar,  measuring  usually  3  inches  by  l^  inches. 
To  the  extremities  of  this  bar  are  riveted  flat  steels 
curving  downwards  and  outwards,  and  upon  the 
lateral  steels,  at  their  extremities  and  at  their 
centres,  plates  of  perforated  tin  are  fastened.  The 
base  piece  is  intended  to  be  incorporated  in  a  plaster 
jacket,  the  transverse  bar  crosses  opposite  the 
second  dorsal  vertebra,  and  the  lateral  pieces  pass 
over  the  scapula  of  each  side. 

The  upright  of  the  jury-mast  must  be  made  of 
tempered  steel,  sufficiently  strong  to  bear  the  weight 
of  a  halter  which  is  attached  to  its  extremity.  It 
is  riveted  below  to  the  centre  of  the  cross-piece  of 
the  base.  It  passes  upwards  to  below  the  occiput 
when  it  is  curved  backwards,  conforming  to  the 
outline  of  the  skull,  but  being  about  1^-  inches 
distant  from  it.  It  ends  over  the  centre  of  the  vertex  and  about  2  inches 
above  it.  To  its  extremity  a  cross-bar  of  narrow  but  strong  tempered 
steel  is  riveted  by  its  centre.  The  cross-bar  extends  laterally  to  a  level 
with  the  lateral  aspect  of  the  skull.  Round  the  chin  and  below  the  occiput 
leather  bands  are  attached.  They  meet  at  a  point  above  the  ear,  and  from 
the  junction  they  are  attached  by  an  adjustable  strap  to  the  extremities  of 


Fig.  75. — The  jury-mast  with 
chest  piece  for  incorpora- 
tion in  a  plaster  jacket. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


181 


the  cross-bar.      The  halter,  the  term  applied  to  the  leather  head  bands, 

should  be  applied  with  as  much  tension  as  can  be  borne  comfortably  by 

the    patient.     The  chin   should    be   tilted  slightly 

upwards  in  order  to  extend  the  cervical  spine,  and 

this  is  done  by  carrying  the  strap  junction  some- 
what forwards  in  front  of  the  ear. 

If  it  is  desirable  to  prevent  lateral  movement  of 

the  head  a  modification  is  applied.     From  the  curved 

upright,  lateral  bands  pass  forwards  above  the  ears, 

and  lie  in  contact  with  the  side  of  the  skull.     They 

extend  forwards  to  a  level  with  the  external  angular 

process,  and  they  are  united  in  front  with  a  strap  of 

webbing.      They    very    efficiently    prevent    lateral 

movement.     The  jury-mast  has   the   advantage  of 

combining  traction  of  the  spine  with  a  certain  degree 

of  fixation.     Its  disadvantage  lies  in  the  fact  that  the 

fixation   afforded   is  by  no   means  absolute.     It  is 

most  frequently  used  in  conjunction  with  a  plaster 

jacket,  but  by  slightly  varying  the  base  piece  it  may 

be  conveniently  fitted  to  any  form  of  spinal  support. 
The  Taylor  Ring-. — This  is  an  attachment  of 

the  Taylor  brace,  and  it  is  used  in  cases  of   caries 

higher  than  the  seventh  dorsal  vertebra.     It  consists 

of    a   ring,  a   spindle,  and  a  socket.      The  ring  is 

oval  in  shape.  Antero-posteriorly  it  extends  from 
occiput  to  the  tip  of  the  chin  ;  later- 
ally it  is  wider  than  the  breadth 
between    the    angles     of     the     iaw.  ^     ,^     ,n,  "m    ,    i  -^i 

°.  J  Fia.  76. — The  Taylor  brace  with 

Opposite  the  left  jaw  angle  a  hinge       the    jury-mast    attached. 
is  placed  which  allows  the  ring  to 
open  horizontally  into  an  anterior  and 

a  posterior  division.  The  halves  are  united  opposite  the  right 
jaw  angle,  with  a  pin  and  a  ring  clasp.  The  ring  is  made 
of  steel  spring,  measuring  J  by  J  inch.  Upon  that  portion 
of  the  ring  which  lies  beneath  the  chin,  a  small  tin  ])late  is 
soldered,  measuring  about  1^  inches  wide  and  f  of  an  inch 
long.  To  the  plate  a  moulded  pad  of  hard  rubber  is  fastened 
to  support  the  chin.     To   the   back  of  the  ring  a   piece  of 


A    case    of    cervico- dorsal 
Pott's  disease. 


The  steel  is  pierced  with  a   hole 


Fio.      77. —  Th.    ,  ,  ,     ■        . 

posterior   spine  forged  steel  IS   riveted 
brace     with    ^IjjqJj  admits  the  top  of  the  spindle.     The  inner  side  of  the 

Tayl  or      ring  .  ^         .  .  ' 

attachment    for    posterior    jjart   of   the    ring    is  covered   with  rubber.      The 
J,'?'.'      ''<»''"''   spindle  is  attached  to  the  brace  by  a  socket  riveted  to  the 

Pott  9  disease.  '  .  ■' 

upright  of  the  brace.  It  is  bent  to  the  curve  of  the  neck,  so 
that  the  ring,  whicii  is  attached  to  it  above,  supports  the  occiput  and  tlie  chin 
at  the  proper  angle.  Above,  the  spindle  enters  the«hole  in  the  steel  at 
the  back  of  the  head-ring.     The  junction  between  the  ring  and  the  spindle 


182  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

permits  of  rotation  of  the  head,  but  this  may  be  checked  by  a  screw.  The 
spindle  is  made  of  soft  steel.  In  its  lower  two-thirds  it  is  flat  in  front  and 
rounded  behind,  in  its  upper  third  it  becomes  circular  to  fit  the  socket  at  the 
back  of  the  ring.  A  shoulder  attached  to  the  spindle  below  the  socket 
prevents  undue  descent  of  the  head  support.  The  socket  by  which  the 
spindle  is  fastened  to  the  brace  is  made  of  machine  steel  J  inch  wide  and 
I  inch  thick.  Through  its  centre  there  is  a  hole  which  admits  the  lower 
flat  end  of  the  spindle.  The  movements  of  the  spindle  in  the  socket  are 
controlled  by  two  set  screws  turning  in  threaded  holes,  and  fitting  into 
depressions  on  the  posterior  half  of  the  socket. 

If  absolute  fixation  of  the  head  is  indicated,  as  in  disease  at  or  near  the 
occipito-axoid  region,  two  steel  uprights  are  attached  to  the  back  of  the 
ring,  and  bent  to  fit  closely  the  posterior  and  lateral  aspects  of  the  head.  A 
band  of  webbing  passes  in  front  of  the  forehead  from  one  upright  to  another. 
In  applying  the  support  the  chin  must  always  be  tilted  slightly  upwards 
in  order  to  throw  the  weight  of  the  head  backwards. 

Shafi'er  has  recommended  that  the  attachment  of  the  ring  to  the  spindle 
should  be  made  by  means  of  a  ball  and  socket  joint  regulated  by  a  screw  and 
key.  This  arrangement  permits  of  an  easier  adjustment  of  the  ring  and 
therefore  of  the  head. 

The  Taylor  ring  has  one  disadvantage — the  continuous  pressure  of  the 
anterior  portion  of  the  ring  upon  the  chin  ultimately  causes  a  recession  of 
that  structure,  with  a  result  which  may  be  exceedingly  unseemly.  If  this 
is  feared,  the  position  of  the  ring  may  be  altered  to  pass  beneath  the  occiput 
and  in  front  of  the  forehead. 

The  Loop  Head  Support. — If  the  disease  in  the  spine  is  at  a  low  level, 
and  all  that  is  required  as  a  head  support  is  something  to  prevent  forward 
inclination  of  the  head,  this  can  be  obtained  by  using  the  loop  head  support. 
It  consists  of  a  loop  of  steel  which,  attached  behind  to  the  cross-bar  or  the 
uprights  of  the  brace,  passes  forwards  in  front  of  the  neck  below  the  chin. 
For  convenience  of  application  it  ought  to  be  provided  ■svith  a  lateral  hinge 
to  enable  the  anterior  portion  to  open  forwards.  Beyond  limiting  flexion 
it  provides  little  support  to  the  head. 

The  Wire  Chin  Rest. — This  application  may  be  used  either  with  a 
plaster  jacket  or  with  a  steel  brace.  The  fixation  which  it  affords  is  unequal  to 
that  of  the  jury-mast  or  the  Taylor  ring.  Its  anterior  part  is  manufactured 
of  wire,  the  posterior  or  occipital  portion  is  of  steel.  The  wire  portion  is  made 
first.  It  is  modelled  in  soft  flexible  wire,  and  completed  in  strong  wire, 
No.  5  or  6  gauge.  A  large  U  with  a  square  foot  is  made  to  fit  the  chest 
in  such  a  way  that  the  transverse  bar  lies  across  the  xiphisternum,  while  the 
vertical  bars  rise  one  on  each  side  over  the  centre  of  the  clavicles  as  far  as 
the  edges  of  the  trapezius  muscles.  These  vertical  bars  are  well  sprung 
forward  when  they  pass  over  the  clavicles,  so  that  no  unnecessary  pressure 
is  exerted.  At  the  edge  of  the  trapezius  the  wire  is  bent  so  that  it  rises 
vertically  upwards  to  behind  and  just  outside  the  angles  of  the  jaw.  It  is 
there  bent  forwards,  and  following  the  line  of  the  lower  jaw  it  passes  beneath 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


183 


the  chin.  When  this  is  satisfactorily  modelled  a  permanent  duplicate  is 
made  in  the  No.  5  gauge  wire,  care  being  taken  that  the  joining  of  the  wire 
occurs  in  the  centre  of  the  transverse  bar  of  the  (J,  not  beneath  the  chin. 
The  wire  portion  is  completed  with  certain  additions.  Under  the  horizontal 
portion  of  the  U ,  and  under  3  inches  of  each  vertical  limb,  there  is  soldered  a 
flat  piece  of  tin  2  inches  wide  and  lined  with  leather.  It  secures  a  good  apposi- 
tion upon  the  chest.  Beneath  the  angles  where  the  uprights  rise  at  the  root 
of  the  neck,  and  extending  for  1|  inches  forwards  and  backwards,  are  soldered 
oblong  pressure  pads  of  steel  f  inch  wide  and  3  inches  long.  Upon  the 
centre  of  the  chin  loop  a  small  piece  of  tin  is  soldered,  with  a  rubber  pad  to 
fit  the  chin  upon  its  upper  surface.  The  occipital  portion  of  the  rest  is  made 
of  a  half -band  of  fiat  malleable  steel  J  by  ^^g-  inch.  By  one  side  it  is  attached 
to  the  right  vertical  wire  behind  the  angle  of  the  jaw,  upon  the  left  side  it  is 
clasped  by  its  hooked  extremity  to  the  corresponding  vertical  wire,  and  where 


Fio.  "8. — The  wire  chiu  rest. 


Fid.  79. — The  Cioklthwait  lieail  .support  for 
cervical  and  cervico-ilorsal  disease. 


it  passes  behind  the  occiput  two  pad  plates  are  fastened.  Vertical  movement 
is  prevented  in  the  posterior  part  by  stops  which  are  soldered  to  the  wire. 

The  principal  advantage  claimed  for  this  apparatus  is  that  of  lightness  ; 
further,  it  is  easily  made  and  requires  no  special  skill.  It  is,  however,  not 
rigid  enough  to  be  an  efficient  support.  Its  use  ought  to  be  limited,  therefore, 
to  convalescents. 

The  Goldthwait  Head  Support.^The  Goldthwait  head  supjxirt  con- 
sists in  the  upper  part  of  a  wire  chin  rest,  fastened  to  yoke-like  metal  bands 
which  pass  over  each  shoulder.  The  yoke-piece  is  first  carefully  moulded  from 
a  strip  of  thin  lead  I  inch  wid(\  From  the  lead  copy  a  careful  paper  pattern 
is  made,  and  a  piece  of  fiat  malleable  steel,  J  inch  wide  and  ^^•  inch  thick, 
bent  to  correspond  with  the  paper  pattern.  In  front  the  yoke  passes  collar- 
wise  acro.ss  the  upper  end  of  the  sternum,  opposite  the  junction  of  the 
manubrium  and  body.  It  bends  backwards  over  the  shoulders,  and  extends 
down  the  back  as  far  as  the  lumbar  region.  The  wire  portion  is  made 
exactly  the  same  as  for  a  wire  chin  rest.     The  u|)riglit  wires  at  their  base  are 


184 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


bent  forwards  for  about  2  inches,  and  soldered  to  the  yoke  on  each  side,  where 
it  bends  over  the  top  of  the  shoulder.  The  apparatus  is  fastened  in  position 
by  straps  and  buckles.  One  strap  encircles  the  body  from  the  tips  of  the 
yoke.  Other  straps  upon  each  side  pass  from  the  yoke  tips  to  buckles  on 
the  curved  portion  of  the  yoke  in  front.  The  apparatus  is  applied  by  opening 
the  posterior  band  of  the  head-piece,  pushing  the  yoke  ends  over  the  shoulders 
and  down  the  back  until  it  falls  comfortably  into  position.  The  posterior 
band  is  then  closed. 

There  are  no  special  advantages  to  be  claimed  for  this  appliance.  It  is 
more  stable  than  the  wire  chin  rest. 

Davies  Head  Support. — This  is  especially  for  use  with  Davies'  quadri- 
lateral back  brace,  but  it  may  be  modified  to  suit  other  forms  of  spinal 
support.  It  consists  of  two  flat  uprights,  a  sling  for  the  occiput,  and  a  strap 
for  the  forehead.  The  uprights  are  bars  of  flat  malleable  steel  ^  inch 
wide  and  -^^  inch  thick.  They  pass  upwards  on  each  side  of  the  middle 
line,  and  they  are  attached  to  one  or  more  of  the  cross-bars  of  the  brace. 
They  are  attached  to  the  cross-bars  by  means  of  sockets  and  set  screws,  so 
that  their  vertical  position  can  be  altered  at  will.  The  uprights  pass  straight 
upwards  to  about  1  inch  below  the  occiput,  when  they  curve  upwards  and 
outwards  to  a  point  1  inch  above  and  ^  inch  behind  the  ears.  Again  their 
direction  alters,  and  they  pass  directly  forwards  to  the  level  of  the  external 
angular  process.  Buckles  are  here  provided  for  attachment  of  the  forehead 
strap,  which  is  made  of  soft  leather  1  inch  wide.  The  occipital  strap  passes 
from  that  portion  of  the  upright  above  the  ear  to  a  corresponding  point  on 
the  opposite  side.  It  passes  behind  the  occiput,  and  it  is  reinforced  on  the 
outside  with  a  thin  strip  of  brass  to  prevent  curling. 

The  Thomas  Collar. — In  disease  of  the  cervical  spine  a  certain  amount 

of  support  and  fixation  may  be  obtained 
by  collars.  Various  materials  have  been 
used  for  this  purpose — poroplaster,  etc. 
The  Thomas  collar  is  the  best  of  this 
type  of  support,  and  it  is  the  only  one 
which  will  be  described.  The  original 
Thomas  collar  was  made  by  stuffing  a 
tube  of  soft  calf -skin  with  sawdust,  the 
diameter  being  greatest  beneath  the 
chin,  and  smallest  under  the  ears.  It 
was  secured  at  the  back  of  the  neck 
with  straps  and  buckles.  A  more  effi- 
\  ^       I     cient  collar  is  made  by  cutting  out  from 

^  J        \    ^  tlii'^  sheet  of  steel  a  metal   pattern 

1  ^  /  1    wide  enough  to  reach  from  the  sternum 

to  the  chin  in  front,  and  from  the  back 
of  the  neck  to  the  occiput.     The  edges  of 
the  metal   are  carefully  turned  out  all 
round,  so  that  no  harmful  pressure  is  exerted  upon  the  neck.     The  metal 


Fig.  80.- 


-The  Tliomas  collar  for  cervical 
Pott's  disease. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  185 

is  covered  with  felt,  and  if  necessary  padded.     When  fitted  round  the  neck 
the  collar  is  secured  in  place  by  a  strap  and  buckle  fastening  behind. 

Many  other  forms  of  support  of  greater  or  less  merit  might  be  described, 
but  space  forbids  their  inclusion.  The  most  important  ones  have  been 
mentioned. 

General  Routine  of  Treatment 

Amidst  the  medley  of  appHances  which  have  been  described,  one  is  apt 
to  lose  sight  of  the  scheme  of  treatment  which  ought  to  underlie  one's 
dealings  with  every  case.  Therefore  it  will  be  of  advantage  at  this  stage  to 
summarise  the  detail  which  has  been  dealt  with,  and  apply  it  in  its  proper 
sequence. 

Recumbency. — It  is  one's  practice  to  treat  every  case  of  the  disease  in 
its  early  stages  by  complete  recumbency,  and  this  is  done  quite  irrespective 
of  the  situation  in  which  the  disease  occurs.  The  recumbency  is  always 
associated  with  some  degree  of  hyperextension  of  the  spine.  The  method 
of  applying  this  and  the  reason  of  its  value  have  been  already  described. 
If  the  disease  is  associated  with  pain  or  considerable  muscular  spasm,  one 
combines  traction  with  the  recumbency  and  hyperextension.  The  traction 
is  continued  until  the  symptoms  disappear. 

Duration. — The  duration  of  recumbency  varies  in  different  parts  of 
the  spine. 

The  Lumbar  Region. — In  the  lumbar  region  the  prognosis  is  good,  and 
in  the  absence  of  complications  one  considers  the  recumbent  period  sufficient 
if  it  extends  over  twelve  months.  The  occurrence  of  symptoms  in  the  shape 
of  psoas  contraction,  night  pains,  and  abscess  formation  must  be  considered 
as  absolute  indications  for  a  further  continuance  of  recumbency. 

Lower  Dorsal  Region. — In  the  lower  dorsal  region  the  duration  of  re- 
cumbency need  not  be  any  longer  than  in  the  lumbar  region.  It  is  a  favour- 
able part  of  the  spine  from  the  view  of  treatment,  because  there  is  not  the 
tendency  to  deformity  which  occurs  higher  up,  and  there  is  an  absence  of 
those  complications  (psoasitis,  etc.)  which  one  finds  in  the  lumbar  spine. 
One  advises,  therefore,  a  minimum  of  twelve  months'  recumbency. 

The  Middle  and  V])per  Dorsal  Regions.—  From  the  point  of  view  of  the 
prevention  of  deformity  this  is  the  most  difficult  region  of  the  spine  to  treat, 
although  symptomatically  it  may  be  quickly  improved.  There  is  no  better 
method  of  preventing  deformity,  and  during  its  early  stages  of  improving  it, 
than  recumbency  combined  with  hyperextension.  The  treatment  must  be 
maintained  for  a  longer  period  than  in  the  other  situations.  Eighteen 
months  is  certainly  the  minimum  required. 

The  Cervical  Region. — This  is  the  most  favourable  region  of  the  spine 
for  treatment.  The  disease  is  rarely  extensive  on  account  of  the  com- 
paratively small  size  of  the  bodies  involved.  The  weight-bearing  necessities 
are  minor,  and  the  tendency  to  deformity  is  correspondingly  lessened.  When 
deformity  does  occur,  the  mobility  of  the  cervical  region  is  so  great  that  it 


186  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

readily  compensates  for  it.     Recumbency  is  carried  out  for  about  six  months, 
and  during  the  greater  part  of  that  time  it  is  combined  with  head-traction. 

The  Occipito-axoid  Region. — Under  efficient  treatment  the  prognosis 
is  good,  and  recovery  without  deformity  should  be  the  rule.  The  proximity 
of  the  disease  to  the  vital  centres  makes  the  prognosis  a  guarded  one,  however. 
The  course  of  the  disease  is  short,  probably  because  it  begins  as  an  arthritis. 
Recumbency  is  carried  out  for  six  months,  and  light  traction  is  maintained 
until  the  symptoms  have  disappeared. 

Type  of  Apparatus. — As  regards  the  apparatus  used  in  carrying  out  the 
recumbency,  one's  best  results  have  undoubtedly  been  obtained  by  the  use 
of  the  Bradford  bed  frame  and  the  Whitman  stretcher  frame.  In  lumbar 
and  lower  dorsal  caries  one  recommends  the  Bradford  frame,  because  the 
tendency  to  deformity  is  small,  and  therefore  little  hyperextension  is  required. 
The  Whitman  frame  is  indicated  in  mid  dorsal,  high  dorsal,  and  cervical 
caries,  as  the  bend  in  the  frame  permits  of  a  thorough  hyperextension  of 
the  spine,  and  a  continuous  double  extension  is  carried  out. 

Ambulatory  Treatment.— With  the  completion  of  recumbency, 
ambulatory  treatment  is  begun. 

Type  of  Apparatus. — One  recommends  that  a  plaster  jacket  or  a  Taylor 
brace  be  the  spinal  support  chosen  ;  both  are  equally  good  but  the  plaster 
case  is  cheaper.  Among  the  poorer  classes  of  patients  one  therefore 
recommends  it  in  preference  to  the  brace.  In  upper  dorsal  and  cervical 
caries  the  plaster  jacket  is  applied  as  a  "  Minerva  "  or  as  a  "  Fillet  "  jacket,  , 
or  a  jury-mast  is  incorporated  into  the  jacket.  Similarly  with  the  brace 
a  head  support  should  be  added,  and  from  experience  one  favours  the 
Taylor  ring. 

If  the  disease  is  low  down,  at  the  lumbo-sacral  junction  for  example,  the 
steel  support  is  better  than  the  jacket,  as  the  former  can  be  carried  lower  down 
and  more  closely  fitted.  And  when  it  is  necessary  to  support  the  head  it  is 
wiser  to  use  a  steel  brace  than  plaster,  because  of  the  better  attachment  for  the 
head-piece.  A  plaster  of  Paris  jacket  is  mcst  useful  in  disease  of  the  spine  from 
the  tenth  dorsal  to  the  third  lumbar  vertebra.^ 

A  spinal  support  of  this  kind  is  worn  for  one  year,  except  in  the  mid 
and  upper  dorsal  regions,  when  it  is  continued  for  eighteen  months.  A  less 
absolute  support  is  then  used,  and  it  has  become  one's  routine  practice 
to  employ  for  this  purpose  a  celluloid  jacket.  This  is  worn  for  a  varying 
period,  from  one  year  to  two,  and  with  its  removal  the  cure  ought  to  be 
complete.     If  any  further  support  is  required  a  light  Knight  brace  is  ordered. 

A  considerable  amount  of  moral  courage  is  necessary  to  insist  upon  the 
completion  of  treatment  so  prolonged,  but  half-measures  are  worse  than 
useless ;  and  it  is  wise  to  thoroughly  explain  the  situation  to  the  parents, 
and  obtain  their  co-operation.  In  one's  out-patient  work  these  cases  are 
detailed  in  a  spinal  case-book  and  register.  They  report  for  examination  at 
stated  intervals,  and  every  effort  is  made  to  trace  the  progress  from  start  to 
finish. 

'  Tubby,  loc.  sup.  cii.  vol.  ii.  p.  103. 


TUBEECULOUS  DISEASE  OF  THE  SPINE  187 

The  Abolition  of  the  Deformity  by  Correction 

Under  this  heading  two  distinct  lines  of  treatment  are  described  :  ( 1 )  A 
rapid  method  of  correction,  in  which  the  ideal  aimed  at  is  to  dispose  of  the 
deformity  at  a  single  sitting.  (2)  A  gradual  method  of  correction,  in  which 
the  obliteration  of  the  deformity  is  carried  out  by  a  series  of  gradual 
corrections. 

(1)  Rapid  Correction  of  the  Deformity. — In  1895  Chipault^  published 
a  paper  in  which  he  described  a  re\'ival  of  a  very  much  older  method  of  cor- 
recting by  force  the  deformity  of  Pott's  disease.  Further  papers  followed  in 
the  successive  years  of  1896  and  1897.  The  method  was  taken  up  by  Calot 
of  Berck-sur-mer,  who  popularised  it,  and  published  an  account  of  it  in  1897.^ 
Since  Calot's  original  publication  hundreds  of  these  operations  have  been 
performed,  and  it  has  been  demonstrated  that  if  suitable  cases  are  chosen, 
it  is  possible  entirely  to  correct  a  Pott's  deformity  at  one  or  more  sittings 
with  but  little  danger  to  the  patient. 

The  Operation. — As  ordinarily  performed,  the  patient  is  anaesthetised 
and  suspended  face  downwards  in  the  horizontal  position  by  five  assistants, 
who  exert  traction  upon  each  of  the  extremities  and  upon  the  head.  There 
need  be  no  fear  of  injuring  the  neck,  as  the  amount  of  force  expended  cannot 
possibly  do  any  harm.  While  the  traction  is  being  exerted,  the  surgeon, 
standing  by  the  side  of  the  patient,  gently  presses  directly  downwards  upon 
the  kyphosis.  The  angulation  gradually  yields  and  straightens,  and  as  it 
does  so,  there  is  often  the  audible  yielding  of  adhesions.  Calot  states  that 
the  amount  of  pressure  required  to  correct  the  deformity  varies  from  30 
to  80  lb.  WTien  the  correction  is  successfully  completed,  or  when  it  has 
been  improved  as  far  as  possible,  the  spine  is  hyperextended,  and  in  this 
position  a  plaster  jacket  is  applied.  If  the  disease  is  in  the  lumbar  or  lower 
dorsal  regions,  the  shoulders  are  braced  well  back  and  included  in  the  jacket  ; 
if  the  disease  is  of  the  upper  dorsal  region,  the  head  and  neck  must  be  in- 
cluded. In  applying  the  jacket  it  is  recommended  that  the  bony  prominences 
be  carefully  jjaddcd  with  thick  felt ;  this  is  probably  unnecessary.  A  large 
window  i.s  cut  out  in  front  to  prevent  interference  with  respiration  or  diges- 
tion. In  tlie  after-fixation  of  the  spine  all  surgeons  do  not  apply  piaster 
jackets  ;  some  prefer  a  well-fitting  brace,  and  others  the  Whitman  stretcher 
frame.  The  after-treatment  consists  in  keeping  the  patient  at  rest  in  the 
recumbent  position  for  from  three  to  six  months.  He  is  then  allowed  to  get 
U])  and  go  about,  but  a  sj)inal  support  is  worn  for  at  least  anotlicr  year. 

hvlications  for  the  Operation.- -The  most  suitable  cases  are  those  in  which 
the  deformity  is  of  short  standing.  In  such,  adhesions  and  changes  in  the 
soft  parts  are  not  sufficiently  developed  to  offer  undue  resistance,  and  the 
internal  organs  have  not  become  displaced  or  c(>m])ressed.  The  middle  and 
iowii'  dorsal  regions  of  the  spine  are  tlie  most  suitable  for  treatment. 

Contrn-indiralinns. — The  most  unfavourable  cases  are   those   of  fixed 

'  Chipault,  Travaux  de  nciiroloijie  cliir.,  IS!).'). 
'  Cal6t,  Archives  prov.  de  chir.,  Feb.   18i)7,  tomo  (i,  N.  2. 


188  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

deformity,  in  which  repair  is  well  advanced  or  completed,  and  in  which  soft 
tissues  and  internal  organs  have  become  altered  in  shape  and  position. 
The  presence  of  an  abscess  should  contra-indicate  the  operation,  but  the 
occurrence  of  paralysis  does  not ;  in  fact,  in  many  instances  the  operation 
relieves  a  paraplegia.  As  a  rule,  deformity  of  the  lumbar  and  of  the 
cervical  regions  is  not  sufficient  to  require  a  forcible  correction. 

Results  of  the  Operation. — One  of  the  most  complete  analyses  has  been 
carried  out  by  Bradford  and  Cotton.^  Six  hundred  and  thirty-nine  cases 
were  corrected  by  thirty-four  operators.  The  time  elapsed  since  operation 
varied  from  a  few  days  up  to  three  years  or  more.  Of  the  isolated 
cases,  in  7  more  than  one  year  had  elapsed,  in  35  more  than  six  months. 
The  total  number  of  deaths  from  all  causes  was  25,  and  the  distribution  as 
follows:  from  various  causes,  5 ;  from  general  tuberculosis,  4;  from  trauma  of 
the  operation  and  chloroform,  5  ;  from  intercurrent  disease,  7.  As  regards 
immediate  consequences  of  the  operation,  7  suffered  from  respiratory 
embarrassment,  6  from  severe  pain,  and  3  from  severe  shock.  In  19  cases 
abscess  was  present  before  operation,  i  of  these  ruptured  with  deleterious 
results,  6  were  benefited  and  in  some  cases  absorbed.  In  two  instances 
abscesses  appeared  after  the  operation.  Paralysis  was  present  before  opera- 
tion in  23  cases,  17  of  these  were  relieved,  2  were  not  reheved,  and  1  case  was 
made  distinctly  worse.  The  operation  was  followed  by  paralysis  in  4  cases. 
As  regards  the  direct  effect  on  the  deformity,  this  was  estimated  in  240 
cases — 130  showed  complete  correction,  94  an  incomplete  improvement.. 
In  77  cases  the  ultimate  result  was  judged  to  be  that  in  20  cases  no  relapse 
had  resulted,  in  50  cases  there  was  some  relapse,  in  7  cases  the  deformity 
had  recurred  as  badly  as  before. 

Jones  and  Tubby  ^  published  in  1898  and  1900  their  experiences  with 
79  cases.  They  found  that  the  results  of  the  operation  were  by  no  means 
discouraging.  In  applying  the  plaster  jacket,  after  rapid  correction 
of  the  deformity.  Tubby  and  Jones  criticise  the  method  recommended 
by  Redard  and  Calot.  They  point  out  the  great  tendency  for  the 
jacket  to  become  infected  with  vermin.  To  avoid  this  they  recommend 
thorough  and  complete  skin  disinfection,  the  use  of  tarry  tow  as  a 
lining,  and  the  application  of  pressure  on  the  hump  by  means  of  boiler 
felt.  They  believe  that  the  amount  of  hyperextension  required  is  so  great 
as  to  make  the  patient's  life  miserable,  and  that  difficulty  during  anaesthesia 
is  a  very  real  danger.  Instead  of  the  plaster  jacket  they  recommend  the  use 
of  a  modified  Thomas  splint.  The  great  disadvantage  of  the  operation 
is  the  marked  tendency  towards  recurrence,  and  the  feeling  at  the  present 
day  is  that  the  method  about  to  be  detailed,  that  of  gradual  reduction,  is 
preferable. 

(2)  Gradual  Correction  of  the  Deformity. — A  beneficial  pressure  is 
exerted  upon  the  deformity  during  and  after  the  application  of  a  plaster 
jacket.      Three  methods   will   be  described  :    (a)  Goldthwait's  method  by 

1  Boston  Med.  and  Surg.  Jounuil,  Sept.  20,  1900. 
2  Clin.  Soc.  Trans,  vol.  xxxi.  p.  19,  and  vol.  xxxiii.  p.  152. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  189 

horizontal  traction  and  leverage  ;    (b)  The  method  of  the  extension  couch 
and  weight  traction  ;    (c)  Calot's  method. 

(a)  Goldthwait's  Method. — This  has  been  alluded  to  in  the  application  of 
a  simple  jacket  (page  169)  and  need  not  be  fully  redetailed.  The  principle 
is  that- the  patient  rests  supine  upon  a  frame  in  such  a  posture  that  the  spine 
is  hyperextended,  and  in  this  position  a  plaster  of  Paris  jacket  is  applied. 
To  secure  the  maximum  hyperextension,  traction  may  be  desirable,  and  if 
so  it  can  be  applied  by  means  of  a  windlass  which  is  attached  to  each  end  of 
the  frame.     The  method  is  repeated  at  intervals. 

(6)  The  Extension  Couch  and  Weight  Traction. — The  patient  is  placed 
on  an  extension  couch,  and  by  leverage  and  weights  the  maximum  degree  of 
correction  is  obtained.  A  steel  support  is  added,  and  the  support  is  provided 
with  advancing  plates  and  screws  which  exert  a  steady  corrective  action 
upon  the  deformity.  The  application  is  maintained  and  repeated  until  the 
correction  is  complete. 

(c)  Calot's  Method  of  Gradual  Correction. — Advantage  is  taken  of  the 
ordinary  plaster  jacket  to  act  as  the  source  of  leverage.  After  the  jacket 
is  applied,  a  small  window  is  cut  out  posteriorly  over  the  deformity  and  a 
large  window  in  front.  The  skin  over  the  deformity  is  covered  with  a  thick 
layer  of  vaseline.  A  number  of  sheets  of  wadding  are  cut,  each  a  little  larger 
in  size  than  the  posterior  window,  and  each  about  1  cm.  in  thickness.  These 
are  carefully  introduced  through  the  posterior  window,  all  around  between 
the  jacket  wall  and  the  skin  over  the  deformity.  For  the  first  compression 
eight  or  ten  layers  of  wadding  are  sufficient.  The  introduced  material 
bulges  out  through  the  opening  on  the  jacket,  and  further  compression  is 
exerted  by  forcing  it  inwards  with  the  successive  turns  of  a  bandage  of 
plaster  of  Paris  or  gum.  The  total  amount  of  wadding  introduced  varies  ; 
if  there  is  no  actual  deformity,  one  insertion  of  eight  or  ten  layers  is  sufficient 
to  guard  against  the  appearance  of  the  deformity.  If  there  is  a  deformity, 
there  will  be  of  course  much  greater  difficulty  in  introducing  a  sufficiency 
of  packing.  At  the  third  or  fourth  insertion  fifteen  to  eighteen  layers  ought 
to  have  been  inserted.  This  may  appear  to  be  an  enormous  amount,  but  it 
is  marvellous  how  quickly  it  becomes  accommodated.  A  gradual  reduction 
of  the  deformity  is  thus  obtained. 

Operative  Treatment  of  the  Gibbosity 

Under  this  heading  one  does  not  iiicliKlc  operative  measures  for  the 
relief  of  abscess  formation,  but  those  wliieli  are  directly  concerned  with  the 
reduction  or  the  fixation  of  the  gibbosity.  Many  years  ago  Calot  advocated 
an  operative  reduction  of  the  deformity.  The  operation  entailed  chiselling 
through  the  ankylosed  vertebraj  and  removing  the  spinous  processes.  Calot 
attempted  to  completely  correct  the  deformity.  This  operation  is  not  now 
performed. 

In  1891  B.  E.  Hadra  '  advocated  the  wiring  together  of  the  spinous 

»  B.  E.  Hadrtt,  Trans.  Amcr.  Orth.  Assoc,  1891,  p.  209. 


190  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

processes  of  the  diseased  and  the  neighbouring  vertebrae.  The  spines  are 
exposed  by  a  median  incision,  the  centre  of  the  incision  being  over  the 
diseased  vertebra.  The  longitudinal  muscles  are  separated  from  each  side 
and  retracted,  and  the  tissues  in  the  interspinous  spaces  are  divided  with  a 
knife.  Silver  wire  is  threaded  in  a  strong,  curved  needle,  and  carried  through 
the  interspinous  spaces  above  and  below  the  processes  in  a  figure  of  eight 
fashion.  The  ends  of  the  wire  are  secured  by  twisting.  In  children  it  is 
advisable  to  wire  at  least  three  spinous  processes,  as  the  tissues  are  apt  to 
lose  their  hold  upon  the  wire  loops.  The  wound  is  completely  closed. 
The  results  of  this  operation  are  disappointing,  and  its  employment  has  been 
abandoned. 

The  next  attempt  at  operative  interference  was  made  by  Lange.^ 
He  advocated  the  replacement  of  external  support  by  internal  splints. 
Splints  made  of  tin-plated  steel  10  cm.  by  5  mm.  are  used.  Incisions  are 
made  through  the  skin  and  fascia  corresponding  to  the  upper  and  lower 
ends  of  the  splints.  The  latter  are  inserted  beneath  the  muscles,  close  to 
the  spinous  processes,  one  on  either  side  of  the  diseased  vertebrae.  The 
splints  are  provided  with  bulbous  extremities,  and  these  extremities  are 
attached  to  the  spinous  processes  by  silk  threads.  For  six  weeks  a  Calot 
plaster  jacket  with  a  posterior  window  is  used,  and  at  the  end  of  that  time 
a  celluloid  jacket.  The  operation  has  two  outstanding  disadvantages — 
the  splints  do  not  afford  sufficient  fixation,  and  they  frequently  give  rise  to 
irritation  and  have  to  be  removed.  More  recent  attempts  have  been  made 
to  fix  the  diseased  vertebrae  with  transplanted  bone,  and  Albee's  ^  operation 
is  based  on  this  principle.  The  patient  is  placed  in  the  vertical  position, 
and  an  incision  is  made  over  the  tips  of  the  spinous  processes  with  the 
kyphosis  in  the  centre.  Each  process  is  split  longitudinally  for  about 
IJ  inches  into  two  portions,  one-third  of  the  process  on  the  left  and  two- 
thirds  on  the  right.  The  soft  tissues  between  the  spines  are  separated  with 
a  scalpel.  Greenstick  fractures  are  produced  at  the  base  of  the  left  one- 
third  portion  of  each  of  the  processes.  A  wedge-shaped  cavity  is  thus 
produced.  From  the  tibia  of  either  leg  a  prism-shaped  portion  of  tibia, 
measuring  4  by  |  by  |  inches,  is  removed,  and  placed  in  the  gap  between 
the  spinous  processes.  The  dense  fascia  over  the  tips  of  the  processes  is 
united  to  keep  the  graft  in  position.  Dobrotworski  *  has  recommended  that 
a  portion  of  rib  be  used  in  preference  to  tibia.  The  immediate  results  of 
this  operation  are  good,  but  sufficient  time  has  not  yet  elapsed  to  enable  one 
to  judge  of  the  ultimate  measure  of  success. 

Dr.  Russel  H.  Hibbs  *  has  recently  introduced  an  operation  which 
aims  to  produce  a  fusion  of  the  posterior  aspect  of  the  vertebrae,  to  obliterate 
motion  of  the  vertebral  articulations  over  the  diseased  area,  and  to  relieve 
pressure  on  the  involved  bodies,  thereby  hastening  the  cure  and  preventing 

1  Lange,  Journ.  Amer.  Orth.  Assoc,  Nov.  1910. 

2  Albee,  Journ.  Amer.  Med.  Assoc.  Chig.,  1911,  Ivii.  885  ;  Post  Graduate,  New  York,  1912, 
xxvii.  999-1017. 

3  Dobrotworski,  Zeilschr.  fiir  Chir.,  Aug.  12,  1911. 
*  Annals  of  Surgery,  May  1912. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  191 

the  deformity.  The  proposal  is  to  accomj)lish  by  operation  what  nature 
attempts  to  do,  viz.  to  eliminate  motion  of  the  diseased  joints  by  an  extra- 
ordinary bony  growth.     The  operation  is  described  as  follows  : 

A  longitudinal  incision  is  made  directly  over  the  spinous  processes  through 
the  skin,  supraspLnous  ligament,  and  periosteum  to  the  tips  of  the  spinous 
processes.  The  periosteum  is  split  over  both  the  upper  and  lower  borders  of 
the  spinous  processes  and  the  laminae,  and  stripped  from  them  to  the  base  of  the 
transverse  processes.  The  spinous  processes  are  partially  fractured,  and  used 
for  bridging  the  gap  between  the  vertebrae.  The  lateral  walls  of  periosteum 
and  of  the  spht  supraspinous  ligament  are  brought  together  over  these  processes 
by  interrupted  chromic  catgut  sutures.  The  skin  wound  is  closed  by  silk  and  a 
steel  brace  applied,  with  the  space  between  the  uprights  increased  somewhat 
at  the  site  of  the  wound,  so  as  not  to  make  pressure  upon  it. 

The  author  reports  a  number  of  cases  with  excellent  results. 

The  Treatment  of  Complications 

Abscess  Formation. — This  has  been  already  thoroughly  discussed 
from  a  general  point  of  view.  It  remains  to  discuss  some  specific  points, 
more  especially  the  various  operative  measures  which  spinal  abscesses 
necessitate.  Abscess  formation  is  a  most  troublesome  complication  of 
Pott's  disease.  It  interferes  with  ajjpropriate  mechanical  treatment,  it 
produces  additional  temporary  and  permanent  deformities  (hip  flexion,  etc.), 
it  extends  the  boundaries  of  the  disease  by  its  ever-present  tendency  to 
migrate,  and  when  it  becomes  secondarily  infected,  prolonged  suppuration, 
waxy  disease,  and  death  may  result.  The  treatment  of  spinal  abscesses 
may  be  grouped  into  three  classes:  (1)  Expectant  treatment;  (2)  Con- 
servative treatment ;   (3)  Operative  treatment. 

1.  Expectant  Treatment. — Of  necessity  this  is  sometimes  the  treatment 
adopted,  because  the  situation  of  the  abscess  is  so  inaccessible  that  other 
measures  are  impossible.  And  in  certain  cases  the  inactivity  is  justified  by 
the  fact  that  the  abscess  spontaneously  resolves  into  a  collection  of  caseo- 
calcareous  debris.  Prevertebral  collections  are  the  most  important  group 
under  this  heading. 

2.  Conservative  Treatment. — By  this  term  one  means  the  treatment  by 
aspiration  and  the  injection  of  various  kinds  of  medicaments.  The  various 
points  have  already  been  fully  discus.sed. 

3.  Operative  Treatment. — This  may  be  the  treatment  of  choice,  and  there 
is  a  school  which  recommends  it  in  every  available  instance  ;  or  it  may 
be  the  treatment  of  necessity  for  the  relief  of  pressure  symptoms  (retro- 
pharyngeal abscesses).  IT  operative  treatment  is  decided  on,  situation  is 
no  bar.  Certain  abscesses  are  more  difficult  of  access  than  others,  but 
almost  without  exception  metliods  liave  been  devised  for  their  exploration. 

Tliere  are  certain  principles  which  ought  to  guide  one's  operative 
techni(pie.  They  are  well  siunmarised  by  Tubby, ^  and  briefly  they  are  as 
follows  : 


•  Tubby,  toe.  aup.  cil.  vol.  ii.  p.  176. 


192  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

(«)  Let  the  patient  remain  recumbent,  and  if  the  abscess  is  increasing, 
allow  it  to  make  its  way  as  much  as  possible  into  a  place  where  it  may  be 
reached  easily. 

(6)  Place  the  incisions  as  far  as  possible  from  sources  of  contamination. 

(c)  Single  incisions  into  abscesses  of  any  size  are  hopeless  ;  at  least  two 
or  three  openings  are  required.  With  a  single  incision  into  a  psoas  abscess 
free  evacuation  from  remote  corners  is  prevented,  because  the  pressure  of 
the  air  on  the  opened  sac  holds  back  the  pus  and  the  caseous  material. 
One  incision  must  be  near  the  source  of  the  mischief,  and  at  least  one  if  not 
more  at  a  distance. 

(d)  Endeavour  to  get  primary  union. 

(e)  Always  apply  firm  pressure  with  pads  along  the  track  of  the  abscess. 
(/)  Asepsis  from  the  first  incision  mi  til  every  drop  of  pus  has  ceased  to 

flow  is  the  prime  necessity,  and  let  the  surgeon  always  remember  that  slips 

in  aseptic  technique  may  cost  the  patient  his  life. 

{g)  Remember  that  recumbency  in  the  open  air  always  assists  the 

disappearance  of  the  abscess. 

Retro-pharyngeal  op  Prevertebral  Cervical  Abscess. — This  abscess 

must  not  be  opened  from  the  mouth,  as 
such  a  procedure  would  certainly  be  fol- 
lowed by  all  the  dangers  of  secondary  in- 
fection. It  is  opened  under  strict  aseptic 
precautions  by  an  incision  behind  the  upper 
third  of  the  posterior  border  of  the  sterno- 
mastoid  muscle.  That  side  is  chosen 
towards  which  the  abscess  inclines.  After 
the  incision  is  deepened  the  spinal  acces- 
sory nerve  is  exposed,  leaving  the  posterior 
border  of  the  muscle,  and  as  it  is  very 
superficial  here,  care  must  be  taken  to  avoid 

Fig.  81. — Incision  for  retro-pbaryiigenl     ...  .  „,  ■        i        i  r    xi 

abscess.  injuring   it.      ihe  posterior   border  of  the 

muscle  is  freed  and  retracted  forwards.  Its 
retraction  can  be  facilitated  if  the  muscle  is  partially  divided  transversely 
just  below  the  mastoid  process.  The  separation  of  the  sterno-mastoid 
exposes  the  fibres  of  the  splenius  and  levator  anguli  scapulse  muscles  as 
they  pass  downwards  from  the  transverse  processes  of  the  vertebrae.  The 
abscess  lies  immediately  in  front  of  the  transverse  processes,  and  its  cavity 
is  entered  by  passing  one's  finger  inwards  along  their  anterior  surface.  The 
internal  jugular  vein,  covered  by  its  sheath,  lies  in  front  of  the  abscess, 
and  it  is  displaced  forwards  by  the  finger  as  the  latter  enters  the  abscess. 
The  cavity  is  emptied  as  completely  as  possible  by  pressure  upon  the  opposite 
side  of  the  neck.  Curettage  is  dangerous  on  account  of  the  liability  of 
perforating  the  posterior  pharyngeal  wall,  and  the  cavity  is  most  safely  and 
thoroughly  cleaned  with  a  plug  of  dry  gauze. 

If  the  abscess  extends  across  the  neck  to  the  opposite  side,  a  counter 
opening  should  be  made  behind  the  opposite  sterno-mastoid.     It  is  wiser 


TUBERCULOUS  DISEASE  OF  THE  SPINE  193 

not  to  close  the  wound  completely,  but  to  secure  drainage  for  a  few  days 
with  a  strip  of  iodoform  gauze  or  rubber  drain. 

After-treatment. — These  cases  require  careful  watching  after  opera- 
tion. A  certain  proportion  of  them  develop  oedema  glottidis,  and  require 
immediate  attention.  The  head  is  immobilised  by  lateral  sand-bags,  and 
it  is  an  advantage  to  apply  weight  extension.  When  the  wound  is  healed, 
steps  must  be  taken  to  secure  fixation  of  the  head  and  the  usual  treatment 
of  tuberculous  spondylitis. 

When  there  is  urgent  dyspnoea  and  dysphagia  it  may  be  justifiable 
to  open  the  abscess  through  the  mouth.  No  ansesthesia  is  used,  or  the  child 
is  kept  very  Ughtl}'  under  with  chloroform.  The  mouth  is  forced  wide 
open  with  a  gag,  and  the  child  is  placed  with  the  head  hanging  well  over 
the  edge  of  the  table  ;   this  obviates  any  possibility  of  aspiration  of  the  pus. 

One  usually  employs  a  fine  tenotomy  knife  to  open  the  abscess,  and 
the  pus  is  swabbed  away  as  quickly  as  possible.  The  child  is  quickly  turned 
over  upon  its  face,  and  kept  in  this  position  until  the  abscess  cavity  is 
evacuated.  The  after-treatment  is  similar  to  that  described  when  the 
abscess  is  opened  from  the  exterior,  but  in  addition  weak  antiseptic 
mouth  washes  are  recommended. 

Supra-clavicular  Tubepculous  Abscesses.— A\T]  en  tuberculous  dis- 
ease of  the  middle  cervical  spine  gives  rise  to  abscess  formation,  the  pus 
passes  outwards  to  the  interval  between  the 
trapezius  and  sterno- mastoid  muscles,  and 
bulges  in  the  posterior  triangle  above  the 
clavicle.  The  operative  procedure  is  very 
similar  to  that  employed  in  the  retro- 
pharyngeal abscess.  An  incision  is  made 
along  the  posterior  border  of  the  sterno-mas- 
toid  muscle  in  its  lower  two-thirds ;  the 
spinal  accessory  nerve  is  defined  and  pre- 
served. The  posterior  border  of  the  sterno- 
mastoid  muscle  is  cleared  and  retracted 
inwards  until  the  outer  edge  of  the  scalenus  F'«-  82.-incision  for  supra-ciavicuinr 

abscess. 

anticus  comes   mto   view.      The   pus   passes 

outwards  between  the  scaleni  and  the  longus  colli  muscles,  and  the  interval 
between  them  is  enlarged  with  the  finger  or  forceps.  The  wound  may  be 
drained  or  immediately  closed.  The  post-operative  treatment  is  similar 
to  that  ali'cady  described. 

Prevertebral  Thoracic  Abscess.  —  As  a  rule  an  abscess  in  this 
situation  gives  rise  to  no  symptoms.  At  first  it  is  a  sul)[)eri()steal  collection 
of  pus ;  the  periosteum  later  becomes  perforated,  ami  the  nuitter  collects 
between  the  mediastinal  pleura  and  the  bodies  of  the  vertebrae.  Operative 
interference  becomes  justifiable  when  pressure  symptoms  appear,  and 
pressure  may  be  exercised  upon  the  oesophagus,  tiie  trachea,  the  left 
recurrent  laryngeal  nerve,  or  the  spinal  cord. 

Operation. — In  some  cases  an  area  of  dulness  may  be  demonstrated 

13 


194 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


upon  one  or  other  side  of  the  spine.  If  the  abscess  Ues  in  the  middle  line 
it  may  not  be  demonstrable  by  clinical  means,  except  by  X-ray  examination, 
and  in  such  cases  it  is  recommended  to  choose  the  right  side  for  one's 
exploration.  The  operation  may  take  the  form  of  a  rib  resection,  or  of 
a  resection  of  the  transverse  process  of  the  vertebra,  together  with  a  portion 
of  the  rib  (costo-transversectomy  ^). 

Rib  Resection. — The  patient  is  placed  semi-prone,  with  the  side  to  be 
operated  on  uppermost.  A  vertical  incision  is  made  parallel  to  the  spinous 
processes,  and  about  1-|  inches  from  the  middle  line.  The  articulations 
between  the  transverse  processes  and  the  ribs  are  exposed.  The  periosteum 
over  the  posterior  surface  of  usually  two  ribs  is  divided  and  separated  from 
the  bone.  A  portion  of  each  rib  is  removed  external  to  the  costo-transverse 
articulation.  The  anterior  periosteum  is  divided,  and  the  finger  is  inserted 
inwards  and  forwards  along  the  anterior  surface  of  the  transverse  process 
and  in  front  of  the  body  of  the  vertebra.  The  abscess  cavity  is  then  opened, 
a  tube  is  inserted,  and  the  cavity  drained.  The  operation  has  three  dis- 
advantages :  (1)  By  this  route  the  abscess  cavity  is  difficult  of  access  ;  (2) 
When  the  cavity  is  entered  the  drainage  secured  is  imperfect ;  (3)  The 
pleura  is  liable  to  be  injured  during  its  separation  from  the  fi'ont  of  the  ribs. 
Costo-transversectomy. — To  obviate  these  disadvantages  the  operation 

,  .^ of  costo-transversectomy  (costo- 

/^  N>  transverse  excision)   was    intro- 

duced by  Heidenhain,  practised 
by  Menard,  and  modified  and 
improved  by  Kocher.  Heiden- 
hain employed  a  straight  vertical 
incision  close  to  the  spines.  The 
soft  tissues  are  separated  out- 
wards from  the  laminae  as  far  as 
the  tubercle  of  the  rib,  the 
transverse  process  is  resected 
first,  and  then  the  head  and  neck 
of  the  rib.  Heidenhain  has 
shown  that  by  the  resection  of 
a  single  costo-transverse  articu- 
lation one  is  enabled  to  introduce 
the  finger,  strip  the  pleura  from 
the  side  of  the  vertebra,  and 
penetrate  the  abscess.  Kocher 
has  modified  the  operation  by 
using  an  oblique  incision,  which 
is  begun  over  the  most  prominent  dorsal  spine,  and  carried  obliquely 
downwards  and  outwards  along  the  line  of  the  rib  which  is  to  be  resected. 


Fig.  83. — Incision  used  in  the  operation  of 
costo-transversectomy. 


'■  The  term  "  costo-transversectomy  "  is  not  a  good  one,  but,  for  its  use,  one  has  the 
precedent  of  many  eminent  authorities.  It  would  be  better  to  employ  the  term  "  costo- 
transverse excision." 


TUBERCULOUS  DISEASE  OF  THE  SPINE  195 

After  dividing  the  integuments,  the  trapezius  and  then  the  rhomboids, 
the  ceUular  interval  is  reached  between  these  muscles  and  the  fascia  covering 
the  divisions  of  the  erector  spinse  (sacro-spinahs)  muscles.  The  longissimus  dorsi 
and  accessorius  (ilio-costalis  dorsi)  are  divided  in  the  line  of  the  original  incision. 

The  cross  division  of  the  deep  muscles  is  of  no  moment,  as  they  possess  a 
segmental  nerve  supply.  .  .  .  The  periosteum  of  the  exposed  rib  is  divided  for 
a  short  distance  external  to  its  tubercle.  The  muscular  attachments,  along  with 
the  periosteum  and  the  posterior  costo-transverse  ligament,  are  then  separated 
from  the  transverse  process,  and  its  base  is  snipped  through  with  a  pair  of  curved 
bone  forceps. 

The  divided  process  is  seized  with  bone  or  necrosis  forceps,  held  in  the  left 
hand,  while  the  knife  is  used  to  free  it  from  the  remaining  ligamentous  attach- 
ments, namely,  from  the  .superior  costo-transverse  ligament,  passing  from  the 
neck  of  the  rib  below  to  its  lower  border,  and  from  the  middle  costo-transverse 
ligament,  which  passes  between  its  anterior  surface  and  the  posterior  aspect  of 
the  neck  of  the  rib  with  which  it  articulates. 

The  next  step  consists  in  the  removal  of  the  head,  neck,  and  tubercle  of  the 
rib.  The  periosteum  is  first  separated  from  the  posterior  aspect  of  the  neck, 
and  a  strong  hook  is  then  inserted  into  the  end  of  the  divided  rib,  which  is  dragged 
backwards,  while  the  periosteum  is  detached  from  its  anterior  aspect,  carrying 
with  it  the  costal  attachment  of  the  anterior  costo-vertebral  (stellate)  ligament. 

When  this  has  been  done,  the  freed  portion  of  the  rib  is  seized  with  necrosis 
forceps  and  twisted  away  from  the  spine.  The  pleura  is  not  injured.  Care 
must  be  taken  not  to  wound  the  intercostal  vessels,  which  pass  outwards  a  little 
below  the  lower  border  of  the  neck  of  the  rib.  If  the  forefinger  be  now  introduced 
into  the  bottom  of  the  wound,  it  will  enter  the  abscess  cavity  which  occupies 
the  ceUular  tissue  of  the  posterior  mediastinum.  ...  If  more  room  be  desired 
in  order  to  reach  the  upper  of  the  two  vertebrae  into  which  the  rib  articulates, 
the  upper  edge  of  the  wound  must  be  retracted,  and  a  second  transverse  process 
removed.  If  the  mediastinal  abscess  be  small  it  may  be  gently  packed  with 
iodoform  gauze  for  a  few  days,  and  the  wound  then  allowed  to  heal.  As  a  rule, 
however,  if  the  cavity  be  large,  and  especially  if  paraplegia  be  present,  a  drainage 
tube  should  be  inserted  and  kept  in  for  a  considerable  time.^ 

When  an  abscess  involves  the  spinal  canal,  it  is  more  satisfactorily 
dealt  with  by  costo-transversectomy  (costo-transverse  excision)  than  by 
laminectomy,  because  the  latter  operation  exposes  the  posterior  part  of  the 
cord  rather  tiian  the  actual  site  of  the  disease. 

After-treatment. — ^The  patient  is  kept  recumbent  for  at  least  one  year 
after  the  operation,  and  if  at  the  end  of  that  time  ambulatory  treatment 
is  begun,  fixation  of  the  spine  must  be  secured  with  a  well-fitting  brace. 

Lumbar  Abscess. — -When  there  is  disease  of  the  lower  dorsal  and  the 
lumbar  .spine,  pus  may  appear  in  the  loin  in  one  of  two  common  situations — ■ 
in  the  angle  between  the  erector  spinas  and  the  last  rib,  or  above  tiie  crest 
of  the  ilium  in  Petit's  triangle. 

Subcostal  Abscess. — -When  the  abscess  lies  beneath  the  last  rib  an  in- 
cision is  made  from  the  outer  edge  of  the  erector  spinaa  beneath  and  paraiK>l 
to  the  rib.  The  latissimus  dorsi  and  the  serratus  posticus  inferior  are 
divided,  and,  lying  deeper,  the  outer  fibres  of  the   quadratus  lumborum 

'  Stiloa,  Bar<jhard'.i  tiijslcm  of  Operative  Sunjcrij,  vol.  ii.  p.  4<i. 


196 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


Fig.  84. 


-Incision  for  the  evacuation  of  a  sub-costal 
abscess. 


and  the  middle  layer  of  the  lumbar  fascia.     The  abscess  is  usually  small  in 
amount,  and  the  wound  can  be  immediately  closed. 

Abscess  in  Petit's  Triangle. 
— An  abscess  in  this  situation 
is  most  commonly  one  which 
has  extended  laterally  into  the 
sheath  of  the  quadratus  lum- 
borum,  and  piercing  the  lamella 
of  the  lumbar  fascia,  has  be- 
come superficial  above  the 
crest  of  the  ilium.  It  may  be 
entered  by  an  oblique  incision 
running  parallel  to  the  pos- 
terior cutaneous  branches  of 
the  lumbar  nerves  ;  that  is  to 
say  passing  obliquely  down- 
wards and  outwards.  Petit's 
triangle  is  exposed,  and  its 
boundaries  are  enlarged  by 
division  of  the  structures  in  its 
posterior  wall,  i.e.  the  outer 
border  of  the  latissimus  dorsi, 
the  quadratus  lumborum,  and 
the  middle  layer  of  the  lumbar' 
aponeurosis.  The  abscess  is  exposed,  lying  close  in  front  of  and  partly  to 
the  outer  side  of  the  transverse  processes  of  the  fourth  and  fifth  lumbar 
vertebrae. 

Treves  advocated  an  extension  of  this  operation,  with  a  view  to  re- 
moving the  disease  in  those  cases  in  which  it  was  localised  to  a  single  vertebra, 
or  was  complicated  by  the  presence  of  a  sequestrum.  Treves'  description 
of  the  operation  is  as  follows  :  ^ 

The  patient's  loin  having  been  exposed,  a  vertical  incision,  some  2|  inches 
in  length,  is  made  through  the  integuments.  The  centre  of  this  cut  should  lie 
about  midway  between  the  crest  of  the  ilium  and  the  last  rib,  and  the  cut  should 
be  so  placed  as  to  correspond  to  a  vertical  Hne  parallel  with  the  vertebral  side 
of  the  outer  border  of  the  erector  spinas.  .  .  .  After  cutting  through  the  super- 
ficial fascia  the  dense  aponeurosis  is  exposed,  which  covers  the  posterior  surface 
of  the  erector  spinae.  .  .  .  The  dense  aponeurosis,  with  its  attached  muscular 
fibres,  having  been  divided  in  the  full  length  of  the  incision,  the  erector  spinae 
is  exposed.  .  .  .  The  outer  border  of  the  muscle  should  now  be  sought  for,  and  the 
whole  mass  drawn  by  means  of  retraction  as  far  as  possible  towards  the  middle 
line  of  the  back.  In  this  way  the  anterior  part  of  the  sheath  of  the  muscle, 
known  as  the  middle  layer  of  the  fascia  lumborum,  is  readily  exposed.  .  .  .  The 
anterior  layer  of  the  sheath,  as  now  exposed,  is  seen  to  be  made  up  of  dense  white 
glistening  fibres,  which  are  all  more  or  less  transverse  in  direction.  Through  this 
sheath  the  transverse  processes  of  the  lumbar  vertebrae  should  be  sought  for. 
The  longest  and  most  conspicuous  process  is  that  belonging  to  the  third  vertebra. 

'  Treves,  A  Manual  of  Operative  Surgery,  vol.  ii.  p.  772. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


197 


.  .  .  The  anterior  layer  of  the  sheath  must  be  divided  vertically  as  near  to  the 
transverse  processes  as  convenient.  By  this  incision  the  quadratus  lumborum 
muscle  is  exposed.  .  .  .  The  muscle  should  be  divided  close  to  the  extremity 
of  a  transverse  process,  and  the  incision  carefully  enlarged  until  the  muscle  is 
divided  to  the  full  extent  of  the  skin  wound.  .  .  .  The  inner  edge  of  the  quadratus 
ia  overlapped  by  the  psoas  muscle,  so  that  when  the  former  is  divided  the  latter 
is  exposed.  .  .  .  Some  of  the  tendinous  fibres  of  the  psoas  having  been  divided 
close  to  a  transverse  process,  the  finger  is  introduced  beneath  the  muscle,  and 
gently  insinuated  along  the  process  until  the  anterior  aspect  of  the  bodies  of  the 
vertebrte  is  reached. 

Iliac  Abscess. — An. iliac  abscess  is  best  opened  by  an  incision  running 
obliquely  downwards  and  inwards,  a  finger-breadth  internal  to  the  anterior 
superior  spine  of  the  ilium,  and  parallel 
to  the  external  oblicpe  fibres.  The 
fibres  of  the  external  oblique  are  split, 
and  internal  oblique  and  transversalis 
muscles  are  split  or  divided.  The 
fascia  transversalis  is  thus  exposed 
close  to  its  junction  with  the  fascia 
Uiaca.  The  dissection  is  carried  out- 
side the  fascia  transversalis,  close  to 
the  anterior  superior  spine,  and  in  this 
way  behind  the  fascia  iliaca.  The 
abscess  cavity  is  entered  from  the 
outer  side.  If  the  abscess  is  prolonged 
downwards  into  the  thigh,  a  second 
opening  must  be  made  at  a  more  de-  / 
pendent  point,  and  for  this  purpose  an 
incision  is  made  a  little  below  the 
anterior  superior  spine  of  the  ilium, 
along  the  curve  on  the  outer  edge  of 

the  sartorius  muscle.  The  abscess  cavity  is  reached  by  pulling  the 
sartorius  outwards  or  inwards,  and  entering  the  thickened  fascia  over  the 
ilio-psoas  internal  to  the  tendon  of  the  rectus  femoris.  When  the  abscess 
cavity  has  been  tlioroughly  emptied  the  incisions  should  be  closed  at  once. 

In  opening  a  psoas  abscess  Wallis  ^  recommends  an  incision  similar  to 
that  employed  for  ligature  of  the  external  iliac  artery. 

The  (tjler  Irenlinenl  consists  in  keeping  the  patient  recumbent  for  at  least 
one  year.  When  he  is  allowed  up,  it  is  with  the  addition  of  a  well-fitting 
spinal  support. 


Fig.  85. — Incision  for  the  evacuation  of  an  iliac 
abscess  secondary  to  tuberculous  disease  of 
the  vertebrae. 


The  Treatment  of  Paralysis 

The  treatment  of  the  paralysis  is  included  in  the  treatment  of  the 
disease  of  wliich  it  is  a  complication,  except  that  even  greater  care  is  taken 
to    secure    fixation    of    the    spine.       When    paralysis    appears,    absolute 

'  VVaUia,  Clin.  Journ.,  March  9,  1898  (Tubby). 


198  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

recumbency  is  indicated,  and  recumbency  in  such  a  position  that  the  spine  is 
hyperextended.  This  is  best  secured  by  a  well-fitting  Whitman  stretcher 
frame.  In  addition  to  fixation  and  hyperextension,  counterextension  should 
be  carried  out  by  means  of  weights  and  pulleys  from  the  head  and  from  the 
lower  limbs.  If  there  is  any  doubt  about  the  amount  of  fixation  secured  by 
the  bed  frame,  it  is  well  to  apply  in  addition  a  well-fitting  brace,  modified 
to  fit  the  change  in  the  shape  of  the  spine  induced  by  recumbency. 

Manipulation  or  massage  of  the  limbs  is  contra-indicated  because  it 
stimulates  the  reflex  centres,  but  the  nutrition  of  the  muscles  may  be  main- 
tained and  improved  by  the  daily  application  of  galvanism. 

The  tendency  to  the  formation  of  trophic  sores  must  be  carefully  guarded 
against  by  attention  to  the  hygiene  of  the  skin. 

If  deformities  arise  from  muscular  contraction,  they  are  corrected  by 
weight  extension  or  if  necessary  by  splints. 

Of  the  internal  remedies,  iodide  of  potash  is  said  to  produce  benefit 
by  causing  the  absorption  of  the  tuberculous  granulation  tissue. 

In  the  treatment  of  paraplegia,  Schilling  ^  recommends  the  use  of  the 
Rauchfuss  sling.  It  consists  of  a  broad  band  of  cotton  or  hnen  webbing, 
suspended  from  one  or  two  cross-pieces,  extending  lengthwise  over  the 
patient's  bed,  and  lifting  the  patient,  at  the  highest  point  of  the  gibbus, 
above  the  surface  of  the  bed,  producing  a  pronounced  lordosis.  The  gibbus 
may  be  protected  against  undue  pressure  by  a  large  water  cushion,  held  in 
place  by  the  sling. 

In  properly  treated  cases,  the  percentage  of  recovery  is  high,  probably 
about  60  per  cent,  but  it  must  be  remembered  that  the  condition  is  liable 
to  relapse. 

When  improvement  appears,  it  will  be  noticed  by  a  lessening  of  the 
muscular  rigidity,  an  increasing  ability  to  move  the  toes,  and  a  diminution 
of  the  exaggerated  reflexes. 

If  conservative  measures  have  been  adopted  for  eighteen  months, 
and  there  is  no  sign  of  improvement ;  if  the  symptoms,  in  spite  of  treatment, 
are  increasing  in  severity  ;  or  if  there  is  evidence  that  the  integrity  of  the 
cord  is  being  threatened  by  the  displacement  of  bone  or  the  pressure  of  an 
abscess,  operative  measures  become  justifiable. 

Operation. — Two  types  of  operation  have  been  tried  :  (1)  Costo- 
transversectomy,  and  (2)  Laminectomy. 

Costo-transversectomy  (Costo-iransverse  excision). — This  has  been  fully 
described  (see  page.  194).  It  is  indicated  in  cases  in  which  the  paraplegia 
results  from  the  pressure  of  an  abscess.  The  results  obtained  by  the 
operation  have  been  encouraging.  Wassiliew  ^  relates  his  experiences  con- 
cerning the  ojDerative  treatment  of  paraplegia  in  tuberculous  spondyUtis  by 
costo-transversectomy.  Of  five  patients  afiected,  in  which  the  pre-vertebral 
space  was  opened,  four  recovered.  In  the  post-operative  treatment  a  drain- 
age tube  is  inserted  into  the  abscess  cavity  and  tincture  of  iodine  injected. 

'  SchiUing,  Deulsclie  Arch.  f.  kUn.  Med.,  June  29,  1905. 
2  WassiUew,  Arcfiiv  f.  Idin.  Chir.  Bd.  88,  No.  3. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  199 

Laminectomy. — Laminectomy  was  first  performed  for  the  relief  of 
paralysis  in  1882.  So  far  its  results  have  not  justified  its  use.  The 
mortality  is  large  (50  per  cent),  and  as  the  posterior  part  of  the  spinal  cord 
is  exposed  rather  than  the  site  of  the  disease,  the  results  of  the  operation  are 
not  good.  It  further  weakens  the  osseous  structure  of  the  spine  upon  which 
one  depends  for  fixation.     Its  procedure  is  briefly  as  follows  : 

"  An  incision  is  made  in  the  middle  line  down  to  the  spines  of  the 
vertebrae  to  be  operated  on,  and  by  means  of  a  periosteum  detacher,  the 
muscles  and  periosteum  are  peeled  off  each  side  so  as  to  expose  the  laminae. 
The  spine  or  spines  are  then  clipped  ofi  with  curved  bone  forceps,  and  by 
means  of  a  saw  the  laminae  are  nearly  sawn  through,  the  division  being 
completed  with  bone  forceps.  The  ligaments  being  then  divided  at  the 
lower  part,  the  plate  of  laminae  and  ligaments  can  be  turned  up  like  the  lid 
of  a  box,  and  either  removed  at  once  or  left  attached,  and  replaced  after 
completion  of  the  operation.  The  cord  is  then  exposed,  covered  with  dura 
mater,  and  the  soft  tissue  in  front  clipped  or  curetted  away.  If  the 
whole  dura  mater  is  thickened  it  can  be  split  open,  and  room  be  obtained 
in  this  way  for  the  cord.  Spicules  of  bone  are  removed  and  pus  evacuated 
if  necessary."  ^  Elsberg  ^  has  recently  published  the  results  which  he  has 
obtained  in  sixty  cases.     His  observations  are  distinctly  encouraging. 

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Roth,  P.  B.     "  Muscular  Spasm  in  Caries  of  the  Spine,"  Lancet,  1911.  i.  903. 
Stienuardt,  I.    D.      "Tuberculosis  of  Spine,   Diagnosis  and  Differential  Diagnosis,"  Arch. 
Diagn.  New  York,  1911,  iv.  276-280. 

Treatment  of  Pott's  Disease 

Galeazzi,  R.  "  Tratlanionto  mochanico delUi  spondylito  tuborcolare,"  Arch,  di  ortop.,  Milano, 
1907,  xxiv.  430-448. 

Openshaw,  T.  H.  "  An  Apparatus  for  obtaining  Extension  of  the  Spine  in  the  Treatment  of 
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Berby,  J.  M.  "The  Treatment  of  Lumbar  Pott's  Disease,  complicated  by  Psoas  Contrac- 
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Epstein.  "  An  easily  constructed  Sling  for  the  Application  of  the  Plaster  Jacket,"  Aw.  J . 
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VooEL,  K.     "  Zur  Technik  des  Gipsverbandes,"  Zenlralbl.  fur  Chir.,  1908,  xxxv.  1242-1244. 

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202  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

FoKBES,  A.  M.     "  The  Treatment  of  Potfs  Disease  of  the  Lumbar  Vertebrae,"  Montreal  M.J., 

1908,  xxxvii.  877-879. 
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Milano,  1908,  xxv.  1-16. 
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1908,  xi.  34. 
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252-254. 
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557. 
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xxxvii.  721. 
ViONARD   et  MoNOT.     "  Corset  plStre  avec  traction  cephalique   pour  mal  de  Pott,"  Lyon 

mid.,  1908,  ex.  778. 
Clarke,  J.  J.     "  Some  Practical  Points  in  the  Treatment  of  Tuberculosis  of  the  Spine," 

B.M.J.,  1908,  ii.  914-916. 
Davis.     "  A  Sling  for  Head  Extension,"  A7ner.  Journ.  Orth.  Surg.,  1909-10,  vii.  234. 
Panton,  K.  D.     "  An  Approved  Method  of  Applying  the  Plaster  Jacket,"  J.  Am.  Med.  Ass., 

1909,  liii.  2155. 
Frieberg,  A.   H.     "  A  Suggestion  for  the  Improvement  of  Plaster  of  Paris  Technique," 

Atner.  Journ.  Orth.  Surg.,  Philadelphia,  1909-10,  vii.  227-229. 
Calot.     "  Le  Traitement  du  mal  de  Pott,"  3Ied.  inf.,  Paris,  1909,  vi.  198-204. 
Frazer.     "An  Inexpensive  Suspensory  Apparatus  for  Pott's  Disease,"  J.  Am.  M.  Ass, 

Chicago,  1909,  liii.  1637. 
Cal6t.     "  Traitement  du  mal  de  Pott,"  Oaz.  mid.  de  Paris,  1909,  no.  44-8. 
Ely,  L.  W.     "The  Treatment  of  Pott's  Disease  at  the  Sea  Breeze  Hospital,"  Med.  Bee, 

New  York,  1909,  Ixv.  1096-1099. 
LovETT,  R.  W.      "  The  Modern  Treatment  of  Tuberculosis  of  the  Spine,"  Cleveland  M.J., 

1909,  viii.  76-88. 

Calot.     "  Le  Traitement  du  mal  de  Pott,"  J.  de  med.  de  Paris,  1909,  2'=  ser.  xxi.  273. 
Selby,  C.  D.     "  Treatment  of  Pott's  Disease,"  Toledo  M.  and  S.  Reporter,  1909,  xxxv.  308- 

311. 
Gallie,  W.  E.     "  The  Treatment  of  High  Dorsal  Potts'   Disease,"   N.  York  M.J.,   1909, 

xc.  14. 
Stern,  W.  G.     "  Non-inflammable  Splints  and  Braces,"  Surg.  Gynec.  and  Obstr.,  1910,  xii.  77. 
Rich,  E.  A.     "  Newer  Therapeutic  Uses  of  Plaster  of  Paris,"  Med.  Sentinel,  Portland,  Oreg., 

1910,  xvKi.  404-409. 

Lanoe,  B.     "  AUmahliches  Redressement  des  Pottischen  Biickels,"  Strassburg  med.  Zeilung, 

1910,  vii.  10-14. 
Sabella,   p.     "  L'  Intervento  precoce  nell'   osteitie  tubercolare  della  colonna  vertebral," 

Policlin.,  Roma,  1910,  xvii.  sez.  Chir.,  250-259. 
Fress,  H.  0.     "  The  Advantages  of  Braces  over  Plaster  Jackets  in  Pott's  Disease,"  Amer. 

Journ.  Orth.  Surg.,  1910-11,  viii,  336-343. 
Wybth,  J.  A.     "  The  Treatment  of  Caries  of  the  Lumbar  Spine  by  Continuous  Extension," 

J.  Am.  M.  Ass.,  Chicago,  1910,  liv.  1299. 
Whitbeck,  B.  H.      "  The  Treatment  of  Pott's  Disease,"  N.    York  Stale  J.M.,  New  York, 

1910,  x.  404-408. 
Lanoe,  F.     "  Die  Behandlung  der  Spondylitis,"  Jahresb.  f.  drztl.  Forlbild.,  Miinchen,  1910, 

9.  Hft.  4-15. 
Mason,  F.  S.     "  Treatment  of  Pott's  Disease  and  Complications,"  Pediatrics,  New  York,  1910, 

xxii.  423-427. 
Brom,  L.  T.     "  A  Portable  Apparatus  for  applying  Jackets  in  Hyperextension,"  Amer.  Journ. 

Orth.  Surg.,  1910-11,  viii.  404-426. 
MoNOD,  G.     "  De  rimmobilisation  des  csteoarthrites  tuberculeuses  (mal  de  Pott  et  ceralgia)," 

Paris  med.,  Paris,  1911,  xix.  141-58. 
Andrieu.     "  Traitement  du  mal  de  Pott  chez  enfants,"  Gaz.  des  hup.,  Paris,  1911,  Ixxxiv. 

1351-1388. 
Merguet,  H.   "  Traitement  du  mal  de  Pott  par  la  methode  de  Lannelongue  modifiee,"  Medecin 

prat.,  Paris,  1912,  viii.  789-792. 
Froelieb.     "  Considt-rations  sur  le  mal  de  Pott,"  Rev.  med.  de  Test,  Nancy,  1912,  xliv.  721- 

736. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  203 

Calve,  J.     "  Traitement  du  mal  de  Pott,"  J.  mid.  frart^.,  Paris,  1912,  ti.  516-527. 
Opexshaw,  T.  H.,  and  Roth,  P.  B.     "  The  Treatment  of  Pott's  Disease  with  an  Analysis  of 

116  Cases,"  Lancet,  London,  1912,  ii.  1708-1710. 
Gauyain,  H.  J.     "  The  Use  of  Plaster  of  Paris  in  the  Mechanical  Treatment  of  Tuberculous 

Disease  of  the  Spine,"  Pracl.,  London,  1913,  xc.  190-202. 
Gattvain,  H.  J.     "  The  Use  of  Celluloid  in  the  T  satmeut  of  Tuberculous  Disease  of  the 

Spine,"  British  Med.  Jourii.,  June  7,  1913. 
Lelievre,  H.     Le  Traitement  orthopedique  du  mal  de  Pott,  Paris,  1912. 
Adam,  S.  D.     "  The  Mechanical  Treatment  of  Spinal  Caries,"  St.  Mary's  Hasp.  Gaz.,  London, 

1913,  xix.  42-44. 
Fboelieb.     "Consideration  sur  le  mal  de  Pott,"  Ann.  de  med.  et  chir.  inf.,  Paris,   1913, 

xrii.  47-59. 
Parby,  L.  a.     ■'  The  Treatment  of  Spinal  Caries  in  Children,"  Antiseptic,  Madras,  1913,  x. 

5-7. 

Abolition  of  the  Deformity  by  Correction 

Hayes.     "  EnquSte  sur  le  traitement  actuel  de  la  gibbosite  du  mal  de  Pott,"  Anjoumed., 

Angers,  1908,  xv.  62-71. 
Redaed,  p.     "  Delia  correzione  deUa  gibbosita  Pottica,"   Arch,   di  ortop.,    Milano,    1908, 

XXV.  34-38. 
Gangele,  K.     "Das  Redressement  altes  Pottisches  Biickels,"  Zeitschr.  f.  orth.  Chir.,  1908, 

xix.  437-444. 
KoFMAKN.  S.     "Die  Erfahrungen  iiber  die  Behandlung  spondylitisches  Biickels  nach  Cal6t," 

Zeitschr.  f.  orthop.  Chir.,  1908,  xxii.  433-439. 
WoLLENBERG,  G.  A.     "  Ubcr  die  Resultate  des  Redressements  des  Pottischen  Biickels," 

Berlin,  klin.  Wochenschr.,  1909,  xlvi.  2055-2057. 
Lanoe,  B.     "  Allmahliohes  Redressement  des  Pottischen  Biickels,"  Zeitschr.  fi'tr  orth.  Chir., 

Stuttgart,  1010,  XXV.  292-302. 

Operativb  Treatment  op  the  Gibbosity 
Kirk,  T.  S.     "  The  Operative  Treatment  ol  Spinal  Caries,"  Med.  Pre^s  and  Circ.,  London^ 

1908,  Ixxxvi.  603-605. 
Newman,  W.      "  Zur  operativen  Behandlung  der  Spondylitis  tuberculosa,"  Beitr.  zu  klin. 

Chir.,  Tubingen,   1909,  Ixv.,  446-461. 
Fioravanti.     L'  Intervento  cliirurgico  nella  cura  dell'  osteit.  tnbercolare  dei  carpi  verlebrali, 

Morgagni,  MUano,   1909,  li.   209-273. 
Whitman.     "Operative  Treatment  of  Pott's  Disease,"  Am.  Surg.,  Philadelphia,  1911,  liv. 

841-847. 
Sachs,  B.     "  Spondylitis  and  some  other  forms  of  Vertebral  Disease,  with  Special  Reference 

to  Diagnosis  and  Oi)orativo  Treatment,"  J.  Nerv.  atid  Ment.  Dis.,  New  York,  and  Lan- 
caster, 1911,  xxxviii.  488-491. 
Albee,  F.  H.     "  Transplantation  of  a  Portion  of  Tibia  into  the  Spine  for  Pott's  Disease," 

Journ.  Am.  M.  Assoc,  Aug.  1911,  Ivii.  885. 
Allison.     "  Review  of  Literature  on  Ankylosing  Operations  in  I'ott's  Disease,"  Interstate 

Med.  Journal,  St.  Louis,  1912,  xix.  456. 
HiBBS.     "  Further  Considerations  of  Operation,"  Am.  Surg.,  Philadelphia,  1912,  Iv.  682-688. 
Albee.     "  A  Further  Report  of  an  Original  Treatment  for  Tuberculosis,  Arthritis  Deformans, 

Old  Fractures,  etc.,"  Post  Qraduate,  Now  York,  1912,  xxvii.   1017-1021. 
Badris.     "  A  New  Ojwration  for  the  Treatment  of  Pott's  Disease,"  Medecin  prat.,  Paris, 

1912,  viii.  220. 
Albee,  F.  H.     "  Bone  Transplantation  as  a  Treatment  of  Pott's  Disease,  etc.,"  Post  Qraduate, 

New  York,  1912,  xxvii.  999-1017. 
RtrOH,  J.  T.     "  The  Treatment  of  Spondylitis  (Pott's  Disease)  by  Bono  Grafting :  Albee's 

Operation,"  Month  Vycl.  and  M.  Bull.,  Philadelphia,  1913,  vi.  78-82. 
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684. 
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Chir..  Stuttgart,  1913,  xxxi.  460-479. 


204  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


HIP-JOINT  DISEASE 
Etiology 

An  infection  of  the  synovial  membrane  of  the  hip-joint  is  designated 
hip-joint  disease,  but  often  the  term  is  somewhat  loosely  applied  to  tuber- 
culous infection  of  the  surrounding  bones.  There  are  certain  factors  which 
infiueuce  the  occurrence  of  the  disease. 

Frequency. — Whitman  ^  found  that  in  a  total  of  7845  cases  of  tuber- 
culous disease  treated  in  the  Hospital  for  Ruptiued  and  Crippled  during 
fifteen  years,  the  distribution  was  as  follows  :  3203  suffered  from  Pott's 
disease,  2230  from  hip  disease,  and  2412  from  diseases  of  the  other  joints. 
These  statistics  bear  out  the  generally  accepted  view  that  disease  of  the  hip- 
joint  ranks  second  in  the  frequency  of  occurrence,  Pott's  disease  being  first 
among  tuberculous  diseases  of  the  bones  and  joints. 

Age. — It  is  essentially  a  disease  of  children.  Ninety  per  cent  of  the 
cases  occur  during  the  first  decade  of  life,  and  to  localise  the  period  more 
exactly,  50  per  cent  of  the  cases  first  appear  in  the  interval  of  two  years,' 
between  3  and  5. 

Sex. — The  disease  is  very  equally  distributed  in  its  occurrence  in  boys 
and  girls.  It  is  probably  the  increased  liability  to  injury  in  the  former 
which  explains  the  slightly  greater  proportion  in  favour  of  boys. 

Side. — The  disease  is  more  commonly  found  on  the  right  side  than  on 
the  left.  In  a  study  of  1000  cases.  Whitman  found  the  right  side  affected  in 
506  instances  and  the  left  side  in  483.  Fortunately  double  hip-joint  disease 
is  exceedingly  rare. 

The  etiological  factors  of  traumatism  and  heredity  differ  in  no  respect 
from  similar  bearings  discussed  as  regards  other  situations. 


Pathology 

Anatomy  of  the  Hip  Joint. — The  hip-joint  is  one  of  the  most  perfect 
examples  of  an  enarthrodial  diarthrosis.  It  combines  a  wide  variety  of 
movement  with  great  stability,  and  yet  its  mechanical  adaptations  are 
such  that  the  erect  attitude  may  be  preserved  without  any  great  degree  of 
sustained  muscular  effort.  The  globular  head  of  the  femur  fits  into  the  deep 
cup-shaped  acetabulum,  the  cavity  of  which  is  increased  by  the  cotyloid 
ligament  attached  to  the  entire  rim  of  the  cup.  The  free  edge  of  this  liga- 
ment is  somewhat  contracted,  so  that  it  actually  grasps  the  head  of  the 

'  Whitman,  Ortliojicedic  Surgery,  1907,  vol.  i.  p.  302. 


HIP-JOINT  DISEASE 


205 


femur  -svliich  it  encircles.  The  acetabular  rim  is  interrupted  in  its  lowest 
part  by  the  acetabular  notch,  and  the  notch  is  partly  filled  up  by  the  trans- 
verse ligament.  Between  the  transverse  ligament  and  the  bone  of  the 
acetabulum,  there  is  a  space  through  which  the  blood-vessels  and  nerves 
enter  the  cup.  The  joint  cavity  is  entirely  invested  by  the  capsular  ligament, 
reinforced  by  ligamentous  thickenings,  to  which  special  names  have  been 
attached — the  iUo-femoral,  pubo-femoral,  and  ischio-capsular  ligaments. 
Passing  from  a  pit  or  depression  on  the  head  of  the  femur  to  the  lower  edge 
of  the  articular  surface  of  the  transverse  ligament  is  the  ligamentum  teres. 
The  bottom  or  non-articular  area  of  the  acetabulum  is  filled  with  a  mass  of 
fat,  covered  with  synovial  membrane — the  so-called  Haversian  gland.  It 
is  continuous  with  the  extra-capsular  fat,  through  the  acetabular  notch, 
and  in  its  base  the  blood-vessels  of  the  synovial  membrane  anastomose  with 
those  of  the  os  innominatum. 
From  a  pathological  point 
of  view,  most  interest 
attaches  to  the  synovial 
membrane.  It  lines  the 
inner  surface  of  the  capsule, 
and  its  distribution  closely 
follows  the  attachment  of 
the  latter,  therefore  it  clothes 
the  femoral  neck  more  com- 
pletely anteriorly  than  pos- 
teriorly. From  the  capsule 
it  is  reflected  close  up  to 
the  articular  margin  of  the 
head  of  the  femur,  and  upon 
the  upper  and  lower  surfaces 
of  the  neck  it  is  redupli- 
cated into  a  number  of 
folds,  which  are  called  the 
cervical  ligaments  of  Stanley, 
prolonged  from  the  inside  of  the  capsule  to  the  inner  or  articular  surfaces 
of  the  cotyloid  and  transverse  ligaments.  It  further  provides  a  covering 
for  the  fat  at  the  bottom  of  the  acetabular  fossa,  as  well  as  a  tubular  invest- 
ment for  the  ligamentum  teres.  Occasionally  a  bui'sa  beneath  the  tendon 
of  the  ilio-psoas  communicates  with  the  interior  of  the  joint  by  a  small 
opening  in  the  capsule. 

Blood  Supply. — The  blood-vessels  supplying  the  liip-joint  arc  derived 
from  tlic  intiTiud  circumflex  and  the  obturator  arteries.  After  perforating 
the  capsular  ligament  they  anastomose  in  the  extra-synovial  tissues,  and 
at  both  the  femoral  and  the  acetabular  extremities  of  the  synovial 
membrane  they  form  a  distinct  circus  vasculosus  ;  that  at  the  femoral  end 
is  more  distinct  than  that  at  the  acetabular.  From  the  synovial  vessels 
there  is  a  conimunicntion  with  those  in  the  interior  of  the  bone,  and  the 


Flo.  8C.— The  hip  joint. 

At  the  acetabular  end,  the  membrane  is 


206  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

anastomosis  is  especially  well  marked  in  two  situations.  Upon  the  under 
sui-face  of  the  neck,  vessels  from  the  cii'cus  vasculosus  pass  along  the 
cervical  ligaments  into  the  bone,  and  at  the  acetabular  extremity  a  junction 
is  established  between  the  circus  vasculosus  and  the  vessels  of  the  interior 
of  the  acetabulum  through  the  pad  of  fat  which  marks  the  attachment  of 
the  ligamentum  teres. 

The  author  ^  has  shown  that  by  injection  of  the  aorta  with  lampblack, 
the  femoral  artery  being  tied  at  the  middle  of  the  thigh,  there  is  produced 
in  the  femur  upon  the  under  surface  of  the  neck  a  wedge-shaped  mass  of 
injection,  sufficient  evidence  of  the  peculiarly  localised  condition  of  the 
anastomosis. 

Patholog'y. — Situation  of  the  Disease. — The  disease  may  originate  in 
the  synovial  membrane  or  in  the  neighbouring  bone.  Konig  found  that 
out  of  15  cases,  the  disease  was  primarily  osseous  in  8  and  synovial  in  7. 
Haberen's  statistics  showed  that  in  132  cases  80  were  certainly  primarily 
osseous,  23  certainly  primarily  synovial,  while  the  origin  of  29  was  doubtful. 
Ashby  and  Wright  believe  that  in  children  the  disease  always  begins  in  the 
bony  tissue. 

Method  of  Infection. — The  infection  is  borne  by  the  blood  stream,  and 
when  it  aSects  the  synovial  membrane  it  is  most  marked  at  the  synovial 
reflexion  and  usually  at  the  femoral  one.  From  the  reflexion  it  spreads 
throughout  the  membrane,  and  it  may  involve  the  underlying  bone.  It  is 
probable  that  a  primary  osseous  focus  is  more  common  than  a  primary 
synovial  one.  The  two  sites  of  election  in  which  the  bone  becomes  diseased' 
are  (1)  a  wedge-shaped  area  upon  the  under  surface  of  the  femoral  neck, 
at  the  diaphyseal  side  of  the  epiphyseal  cartilage  ;  (2)  upon  the  surface 
of  the  acetabulum,  where  the  Haversian  pad  of  fat  is  situated.  Both 
of  these  situations  are  explained  by  the  vascular  distribution  already 
described.  The  situation  is  influenced  by  two  factors — by  the  position  of 
the  reflexion  of  the  synovial  membrane,  and  by  the  site  of  entrance  of  the 
anastomosis  between  the  synovial  and  the  osseous  blood-vessels  ;  therefore 
it  is  that  the  epiphysis  is  never  infected  unless  secondary  to  disease  of 
the  joint,  while  the  under  surfaces  of  the  metaphysis  is  so  frequently  the 
situation  of  disease.  From  the  bone  focus  the  synovial  membrane  may  be 
infected  secondarily. 

Whether  synovial  or  osseous  in  its  origin,  the  disease  soon  becomes 
general.  The  synovial  membrane  is  converted  into  tuberculous  granulation 
tissue.  The  joint  cavity  becomes  filled  and  distended  with  fluid  and  debris. 
The  articular  cartilages  become  diseased  and  detached.  The  spaces  of  the 
underlying  bone  become  filled  with  tuberculous  granulation  tissue,  and 
the  rarefaction  coupled  with  the  pressure  of  the  body  weight  pro- 
duces an  absorption  and  disappearance  of  the  bone.  The  femoral  head 
is  gradually  destroyed,  and  it  may  become  detached  at  its  epiphyseal 
cartilage.  The  femoral  neck  is  shortened,  and  a  wedge-shaped  sequestrum 
is   commonly  found  on  its   under   sui-face.      The   acetabulum  is   eroded 

1  Fraser,  "  The  Situation  of  the  Lesion  in  Osseous  Tubercle,"  Edin.  31.  Journ.,  Nov.  1912. 


HIP-JOINT  DISEASE  207 

upwards  and  backwards  from  the  pressure  of  the  opposiug  head,  and 
frequently  its  base  is  destroyed  and  the  pelvic  cavity  penetrated.  The  soft 
tissues  around  the  joint  become  invaded  by  the  disease  and  peri-articular 
cold  abscesses  develop.  From  an  osseous  focus  the  abscesses  appear  extra- 
synovial,  and  usually  upon  the  inner  side  of  the  joint  among  the  adductor 
muscles  of  the  thigh.  From  synovial  disease  it  often  first  involves  the 
biusa  beneath  the  iUo-psoas  tendon,  and  an  abscess  develops  upon  the 
front  of  the  joint. 

The  migration  and  destruction  of  the  acetabulum  and  the  gradual 
absorption  of  the  head  and  neck  of  the  femur  produce  a  shortening  of  the 
limb  and  a  displacement  from  its  natural  position.  There  is  a  secondary 
contraction  of  the  longitudinal  pelvi-crural  muscles.  AATien  the  disease  is 
well  marked  and  has  existed  for  some  time,  the  blood-vessels  in  the  neigh- 
bourhood of  the  joint  become  thickened  by  a  process  of  endarteritis  obliterans, 
and  many  years  ago  A.  G.  Miller  pointed  out  that  this  toxic  endarteritis 
affected  the  femoral  artery,  producing  a  considerable  diminution  in  its 
bore.  The  endarteritis  is  probably  responsible  for  a  considerable  amount 
of  the  muscular  atrophy  which  is  so  characteristic  of  the  disease.  A 
natural  cure  results  in  one  of  several  ways  :  By  absorption  of  the  tuber- 
culous tissue  at  an  early  stage  of  the  disease,  by  calcification  of  the  material 
at  a  more  advanced  stage,  or  by  evacuation  and  discharge  through  an 
external  opening.  The  last  is  the  method  which  nature  most  commonly 
employs.  When  the  disease  is  purely  osseous,  changes  occur  in  the  joint 
which  are  not  tuberculous  but  reflex  in  origin,  and  are  secondary  to  the 
irritation  of  the  bone  focus.  These  changes  consist  in  hyperaemia  of  the 
synovial  membrane  and  an  accumulation  of  clear  fluid  within  the  joint 
cavity. 

Summapy. — In  a  well-established  case  one  would  summarise  the  patho- 
logical appearances  as  follows  :  The  interior  of  the  joint  is  filled  with  a 
varying  quantity  of  fluid,  usually  semi-purulent,  and  containing  a  quantity 
of  debris.  The  synovial  membrane  is  irregular,  in  some  parts  thickened 
with  a  grey  cedematous  appearance,  in  others  ulcerated  and  eroded.  The 
cartilage  is  in  one  of  two  conditions  :  it  is  either  fibrous,  wasted,  and  pitted 
in  appearance  (perichondral  ulceration) ;  or  it  is  of  a  dull  yellow  colour,  and 
is  being  detached  from  the  underlying  bone  in  flakes  (subchondral  ulceration). 
When  the  bone  is  not  actually  diseased  its  structure  is  nevertheless  altered, 
the  bone  lamellae  are  rarefied,  and  the  spaces  are  filled  with  a  yellow 
myxomatous  marrow.  The  bone  which  is  actually  diseased  looks  eroded  and 
worm-eaten.  There  are  irregular  ca\'ities  filled  with  tuberculous  granulation 
tissue  in  varying  stages  of  development.  There  are  many  small  sequestra, 
and  frequently  a  wedge-shaped  one  of  appreciable  size  upon  the  under 
surface  of  the  neck. 

The  contour  of  the  head  and  neck  may  be  considerably  altered  ;  the 
complete  head  may  be  loose  m  the  joint  cavity,  separated  at  its  epiphyseal 
attachment.  The  neck  may  be  shortened  by  absorption  in  its  long  axis, 
or  it  may   bo  altered   in   its   angle   into  a  condition  of  coxa   vara.     The 


208 


TUBEECULOSIS  OF  THE  BONES  AND  JOINTS 


acetabulum  is  affected  primarily  or  secondarily.  Primarily  it  is  the  result 
of  disease  originating  in  its  substance,  when  there  is  an  area  of  erosion  in 
the  lower  part  of  its  floor.  Secondarily  it  is  due  to  absorption  jJroduced  by 
the  pressure  of  the  femoral  head,  and  an  extension  of  the  acetabular  cavity 
upwards  and  backwards — a  wandering  acetabulum.  The  capsular  ligament 
and  its  accessories  are  softened  and  relaxed ;  the  ligamentum  teres 
early  becomes  invaded  and  disappears.  In  the  extracapsular  tissue  cold 
abscesses  may  develop  upon  the  anterior  and  the  internal  aspects. 


Symptoms 

The  onset  is  usually  insidious.     The  history  is  often  introduced  by  the 


Fia.  S7.  —  i'lii-i  pliotograph  illustrates  the  "early" 
variety  of  limp  in  right  hip-joint  disease.  The 
knee  is  bent,  the  pelvis  tilted  down,  and  the 
limb  abducted. 


Fig.  SS.— The  gait  in 
advanced  hip-joint  disease. 


account  of  an  injury,  sustained  a  varying  period  before.  The  value  to  be 
attached  to  such  a  precedent  has  been  discussed,  but  it  occurs  too  constantly 
to  be  entirely  neglected. 

Stiffness. — A  stiff  joint  in  the  morning  is  an  early  symptom.  When  the 
child  first  rises  the  stiffness  is  remarked  upon,  but  as  the  day  passes  it  gradually 
lessens,  and  by  night-time  it  has  disappeared.  It  may  appear  on  getting 
up  after  a  rest  of  a  few  hours.  It  is  supposed  that  pathologically  it  corre- 
sponds to  an  early  stage  of  the  disease,  which  is  associated  with  a  diminution 
in  the  amount  of  synovial  fluid  and  an  alteration  in  its  healthy  composition. 
The  stiffness  results  from  this.  As  movement  is  re-established,  the  vas- 
cularity of  the  synovial  membrane  increases,  a  further  amount  of  synovial 


HIP-JOINT  DISEASE 


209 


fluid  appears,  the  joint  surfaces  are  better  lubricated,  and  the  stiffness 
disappears. 

Lameness. — There  is  a  certain  degree  of  temporary  Hmp  associated 
with  the  stiffness,  and  this,  at  first  almost  unnoticeable,  later  becomes  well 
established.  There  are  two  varieties  of  limp — early  and  late.  The  early 
limp  is  an  effort  to  avoid  weight-bearing  by  the  diseased  hmb,  the  knee  is 
slightly  bent,  and  the  pelvis  tilted  down,  the  thigh  is  somewhat  abducted,  the 
toes  are  pointed  and  the  foot  everted.  The  patient  spends  as  little  time 
as  possible  upon  the  diseased  limb.  The  late  limp  is  partly  due  to  pain 
and  stiffness  in  the  joint,  but  in  addition  it  is  secondary  to  mechanical 
alterations  in  the  relative  positions  of  the  bones — adduction,  abduction, 
etc.     Its  characteristics  are  discussed  later  among  the  physical  signs. 

Pain. — Few  cases  have  pain  directly  locahsed  to  the  hip.  It  is  usually 
referred,  by  a  nerve  distribution,  either  to  the  front  of  the  thigh  or  the  inner 


FlO.  89.— Tlu-riM;^tiilHrriil.«i.s  .li-vnsi-  of 
the  right  hip-joiut.  The  feet  .show 
the  "]jositioii  of  self- protection  "  in 
which  the  tliseiused  limb  is  supported 
by  the  foot  of  the  healthy  side. 


r..  [to. — The  "position  "f  M'll-|jio- 
tection  "  in  a  more  atlvauceil  case 
of  hip-joint  ilise.ise.  Extension  is 
being  maintained  by  the  pressure 
of  the  foot  of  the  opposite  side. 


side  of  the  knee-joint.  As  the  disease  progresses  and  malpositions  appear, 
pain  may  then  be  localised  in  the  joint.  It  is  due  to  abnormal  pressure 
of  adjacent  bony  surfaces  or  to  tension  upon  ligaments  or  muscles. 

Self-protection. — The  child  learns  by  experience  that  jars  and  move- 
ments increase  the  local  or  referred  pains,  and  to  diminish  the  chance  of 
injury,  attitudes  are  adopted  which  may  be  called  "  positions  of  self- 
protection."  They  are  really  points  for  discussion  in  the  physical  examina- 
tion, but  they  are  often  included  and  mentioned  in  the  symptomatic  history. 
These  positions  of  self-protection  are  of  two  kinds  :  (1)  In  tlie  early  stages 
of  the  disease  an  attitude  is  taken  up  which  steadies  the  affected  limb.  The 
toes  of  the  healthy  foot  are  placed  beneath  the  sole  of  the  diseased  foot, 
so  as  to  steady  and  support  the  latter.  (2)  At  a  later  period,  when  the 
disease  has  become  more  established,  extension  is  required  for  the  relief  of 
symptoms.  The  patient  ingeniously  obtains  extension  by  resting  the  sole 
of  the  healthy  foot  upon  the  dorsum  of  tlic  diseased  one,  and  gradually 
extending  the  diseased  limb  by  means  of  the  healthy  one. 

14 


210 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


Night  Cries. — Night  cries  are  present  sooner  or  later.  As  the  child 
drops  off  to  sleep,  the  muscles  which  during  consciousness  have  fixed  the 
joint  in  a  painless  position  relax,  and  the  joint  in  consequence  moves.  The 
child  wakens  with  a  startled  cry,  and  does  not  know  what  hurt  him.  The 
cries  are  typical  of  most  forms  of  tuberculous  joint  disease. 

Changes  in  General  Health. — While  a  few  patients  retain  their  general 
health  for  a  time,  the  majority  are  debilitated  from  the  first.  The  onset  of 
the  disease  is  marked  by  general  malaise  ;  the  child  becomes  cross  and 
restless.  The  appetite  begins  to  fail,  and  the  weight  lessens.  There  is 
often  a  slight  rise  of  temperature  in  the  evening.  If  abscess  formation 
occurs  the  general  symptoms  become  more  marked.  The  loss  of  health 
is  rapid,  and  the  evening  temperature  may  reach  a  height  of  101  or  102 
degrees.  When  the  disease  is  complicated  by  sinus  formation,  then  and 
almost  essentially  by  a  mixed  infection,  the  symptoms  of  cachexia  and  waxy 
disease  may  appear. 

Physical  Examination 

Physical  Sigrns. — The  child  must  be  stripped  from  the  waist  down- 
wards, and  a  thorough  routine  examination  gone  through. 

General  Inspection. — Appearance. — The  child  may  appear  wonderfully 
well-nourished  and  healthy,  but  more  commonly 
there  is  some  loss  of  flesh,  and  the  face  acquires  a 
prematurely  aged  and  distinctly  anxious  expression. 
Position  of  Limbs  at  Rest. — Mention  has  been 
made  of  the  two  attitudes  of  self-protection,  one 
securing  fixation  of  the  limb,  the  other  providing 
extension.  There  are  other  alterations  in  position 
which  may  be  called  distortions  of  the  limb.  They 
are  combined  varieties  of  flexion,  abduction,  adduc- 
tion, external  rotation,  internal  rotation,  apparent 
lengthening,  apparent  shortening,  actual  shortening, 
and  lordosis.  These  deformities  have  been  grouped 
together  in  various  ways,  and  by  their  arrangement 
they  have  been  responsible  for  the  division  of  hip 
disease  into  three  different  stages.  The  deformity 
of  the  first  stage  may  be  one  of  pure  flexion,  or  a 
slight  degree  of  flexion  combined  with  some  abduc- 
tion. Pathologically,  the  period  corresponds  to  a 
pure  synovial  lesion,  or  to  a  bone  lesion  which  has  not 
yet  opened  freely  into  the  joint.  The  explanation 
of  the  deformity  is  partly  a  reflex  muscular  irrita- 
tion and  partly  a  voluntary  effort  to  reduce  the 
shock  and  jar  upon  the  sensitive  limb. 

The  second  stage  is  typically  represented  by  a  posi- 
tion of  flexion,  abduction,  and  eversion.  AVhen  the  deformity  is  corrected 
there  is  a  lordosis  of  the  lumbar  spine  and  an  apparent  lengthening  of  the 


Fig.  91. — Positiou  of  tlie 
limb  associated  with 
tuberculous  disease  of 
tlie  right  hip-joint.  The 
positiou  is  oue  of  He.xiou, 
abduction,  aud  external 
rotation. 


HIP-JOINT  DISEASE 


ni 


Fig.  92. — Position  of  the  affected  limb  in  aiUuiieol  liip- 
joint  disease.  Tlie  limb  is  held  in  a  position  of  flexion, 
adduetion,  and  internal  rotation. 


affected  limb.  The  apparent  lengthening  results  from  bringing  the  abducted 
limb  parallel  to  its  fellow.  This  can  only  be  accomplished  by  a  consider- 
able tilting  downwards  of  the  pelvis  upon  the  affected  side,  and  a  resulting 
apparent  lengthening  of  the  limb.  The  disease  in  the  joint  has  become  at 
this  stage  more  extensive, 
and  it  has  been  said  that  the 
deformity  is  the  result  of  an 
accumulation  of  fluid  within 
the  joint.  The  articular  car- 
tilages are  being  destroyed, 
and  there  is  progressive  in- 
volvement of  all  the  struc- 
tures of  the  joint. 

The  explanation  of  the 
deformity  may  be  partly  the  accumulation  of  fluid  within  the  capsule,  but 
it  is  more  probably  the  attitude  which  gives  the  greatest  relief  from  pain, 
and  therefore  assumed  both  consciously  and  unconsciously. 

The  third  stage  of  the  disease  is  characterised  by  flexion,  adduction, 

and  inversion,  with  apparent  or  real 
shortening.  The  flexion,  adduction, 
and  inversion  are  mechanically  com- 
bined, for  as  the  joint  irritation  in- 
creases the  more  powerful  adductors 
overcome  the  weaker  abductors.  The 
apparent  shortening  is  secondary  to 
the  adduction,  as  bringing  the  limbs 
jiarallel  must  of  necessity  raise  the 
|ielvis  upon  the  affected  side.  Real 
shortening  has  several  explanations, 
it  may  be  due  to  partial  or  entire 
absorption  of  the  head  of  the  femur, 
widening  and  migration  of  the  ace- 
tabulum, atrophy  of  the  bone,  and 
retardation  of  growth,  a  coxa  vara, 
or  a  pathological  dislocation  of  the 
f<'nioral  head.  It  must  be  remem- 
bered that  these  combinations  of 
deformity  are  not  universally  con- 
stant, but  they  are  sufficiently  so 
to  form  a  convenient  mode  of  sub- 
1  lassifying  the  disease. 

Allemtions  in  Walking.    The  Limp 
and  its  Churaclcri.slic.s.   -From  being  at 
first  almost  imperceptible,  the  lame- 
ness increases,  and  the  limp  becomes 
In  exceptionally  acute  cases  of  the  disease  the 


Fl(i.  !i:).- The  {,'ait  in  advaneed  left  hip-jnint 
disease.  The  pelvis  is  tilted  npwards  on 
the  left  side  to  aeconimodatc  for  the  adduc- 
tion which  is  present. 


more  and  more  noticeable. 


212 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


pain  may  be  so  severe  that  the  child  may  refuse  absolutely  to  use  the  leg, 
or  the  malposition  may  be  so  excessive  that  walking  is  impossible.  But  in 
general,  walking  with  a  limp  is  carried  on  untU  late  in  the  course  of  the  illness. 
At  first  the  limp  is  the  result  of  stiffness,  and  its  characteristic  is  a  tendency 
to  drag  the  affected  limb.  The  foot  is  not  lifted  freely  from  the  ground, 
but  is  swung  round  in  an  everted  position  with  each  step.  As  the 
disease  progresses  a  more  decided  limp  appears.  There  is  a  change  in  the 
rhythm  of  the  gait,  a  long  step  alternating  with  a  short  one.  The  foot  is 
held  pointed  and  the  weight  is  borne  upon  the  anterior  portion  of  the  foot. 
At  a  later  period,  and  before  walking  is  given  up,  the  lameness  is  pitiful. 
The  hip  and  knee-joints  are  flexed,  and  there  is  a  lordosis  in  the  lumbar 
spine.  The  foot  is  strongly  pointed,  and  the  patient  walks  upon  the  very 
front  of  the  foot.  The  shortest  possible  time  is  spent  upon  the  affected 
limb,  and  with  each  step  there  is  a  drooping  of  the  pelvis. 

Alteration  in  Contour  of  the  Joint  and  its  Surroundings. — When  the  child 
is  stripped  for  examination,  the  surgeon  immediately  notices  the  wasting  of 
the  muscles  of  the  affected  limb.  The  cause  is  doubtful ;  it  is  said  to  be 
reflex  and  secondary  to  the  disease  in  the  joint.  Recent  experiments  of 
A.  T.  Legg  would  seem  to  point  to  the  fact  that  it  is  largely  the  result  of 
disuse.     The  wasting  is  most  marked  in  the  buttock  of  the  affected  side. 

There  are  alterations  in  the  groin  fold 
and  in  the  buttock  fold.  The  groin 
fold  disappears  when  the  limb  is 
abducted  and  rotated  outwards.  Its 
depth  is  increased  when  the  limb  is 
adducted  and  rotated  inwards.  Its 
depth  is  also  increased  with  flexion  of 
the  limb.  As  regards  the  gluteal  fold, 
its  position  is  lowered  and  its  depth 
diminished  when  the  limb  is  flexed, 
abducted,  and  rotated  outwards.  The 
fold  is  elevated  and  its  depth  dimin- 
ished if  the  limb  is  flexed,  adducted, 
and  rotated  inwards.  The  great 
trochanter  is  more  prominent  when  the 
leg  is  adducted  ;  it  is  less  so  when  the  Umb  is  abducted.  A  localised  ful- 
ness may  be  noticed  around  the  outline  of  the  joint ;  it  usually  means  the 
formation  of  a  cold  abscess.  A  bulging  in  front  of  the  groin  may  mean  an 
enlargement  of  the  ilio-psoas  bursa,  and  this,  according  to  D'Arcy  Power,  is 
an  early  sign  of  disease  of  the  underlying  joint.  Wright  attaches  consider- 
able importance  to  an  enlargement  of  the  inguinal  glands. 

Palpation  of  the  Joint  and  the  surrounding-  Bony  Outlines. — It  is 
possible  to  palpate  the  capsule  of  the  joint  by  sinking  one's  fingers  inwards 
behind  the  trochanter.  An  effusion  into  the  joint  may  thus  be  appreciated, 
and  when  the  joint  is  diseased  the  region  is  tender  to  pressure.  It  is  not 
possible  to  investigate  the  joint  by  anterior  palpation.   The  soft  tissues  around 


Fia.  94. — Alteration  of  the  contour  in  left 
hip-joint  disease.  Note  the  wasting  of 
the  buttock,  the  persistent  muscular 
spasm,  and  the  diminution  in  depth  and 
lowering  of  the  gluteal  fold. 


HIP-JOINT  DISEASE  213 

are  carefuUy  investigated  for  the  presence  of  inflammatory  effusions  and  cold 
abscesses.  Examination  of  the  rectum  must  never  be  omitted,  by  it  alone 
can  an  intra-pelvic  effusion  be  recognised.  The  trochanter  is  palpated, 
and  its  size  compared  mth  that  of  the  opposite  side.  Osseous  disease  is 
often  associated  with  a  distinct  enlargement  of  that  portion  of  the  bone. 
By  the  delineation  of  Nekton's  lines  and  Bryant's  triangles,  an  idea  is 
gained  of  the  presence  and  the  degree  of  elevation  of  the  trochanter.  One 
expects  an  elevation  when  there  is  absorption  of  the  neck  of  the  bone  or 
migration  of  the  acetabulum.  This  portion  of  the  examination  is  concluded 
by  palpating  the  ihac  fossa  to  exclude  the  presence  of  an  iliac  abscess,  and 
by  examining  the  groin  for  the  presence  of  enlarged  lymphatic  glands. 

Muscular  Spasm. — Muscular  spasm  is  the  "  spUnt "  which  natm'e 
employs  to  reduce  the  discomfort  and  pain  of  joint  movements.     It  may  be 


Fig.  95. — Thomas's  test  to  demonstrate  tlie  jicrsisteut  muscular  spasm  iiroduciug 
flexion  of  the  right  hip-joint  iu  hip-joint  disease  (right). 

present  only  at  the  extremes  of  movement  in  one  or  more  directions,  or  it 
may  be  so  absolute  as  to  simulate  ankylosis.  It  disappears  entirely  under 
ansesthesia,  and  reappears  with  returning  consciousness.  Its  origin  is  a  double 
one  ;  it  is  due  in  part  to  a  reflex  stimulus  induced  by  the  diseased  synovial 
membrane,  and  in  part  to  a  voluntary  effort,  preventing  the  coaptation  of 
diseased  articular  surfaces.  The  phenomenon  becomes  at  once  obvious 
when  joint  movements  are  investigated,  but  its  presence  may  be  demon- 
strated without  arousing  the  pain  which  movement  induces.  Its  occurrence 
is  shown  by  manipulating  the  sound  limb  and  observing  the  related  changes 
in  position  of  the  suspected  leg.  By  fully  flexing  the  sound  liinl),  the  lumbar 
spine  is  pressed  firmly  upon  the  table,  and  any  lordosis  which  may  liave 
existed  is  abolished.  If  lordosis  has  existed  its  presence  may  have  been 
sufficient  to  mask  a  persistent  flexion  of  the  hip-joint,  but  when  the  lordosis 
is  corrected  the  flexion  of  the  hip  at  once  becomes  apparent  (Thomas's  test). 
The  flexion  is  the  result  of  a  persistent  nuiscuiar  spasm.     Similarly,  move- 


214 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


ments  of  abduction  in  the  sound  limb  will  be  accompanied  by  adduction  of 
the  affected  leg,  and  adduction  of  the  one  by  abduction  of  the  other. 

Examination  of  Joint  Movements.— It  is  one  of  the  most  striking 
characteristics  of  hip- joint  disease  that  the  muscular  spasm,  which  the  disease 
gives  rise  to,  induces  a  considerable  limitation  in  the  movements  which  a 
healthy  joint  ought  to  possess.  Each  movement  ought  to  be  examined  in 
detail.  This  is  a  stage  of  the  examination  which  may  be  associated  vnth 
considerable  pain  to  the  patient,  and  it  must  be  accomplished  as  gently  as 
possible.  To  gain  the  sufferer's  confidence  and  to  help  in  disarming  his 
suspicion,  it  is  well  to  begin  by  manipulating  the  healthy  limb.  The  move- 
ments of  which  the  hip-joint  is  capable  are  those  of  flexion,  extension, 


Fic.  9i;. — The  uiainriivrr  ti 


iiistrate  tlie  movements  u(  rotation  at  tlie  hip-joint. 


abduction,  adduction,  rotation,  and  circumduction.  Flexion,  abduction,  and 
adduction  are  investigated  while  the  patient  lies  on  his  back.  The  examiner 
steadies  the  pelvis  with  his  left  hand  by  placing  the  fingers  upon  the  ilium 
and  sacrum,  and  the  thumb  on  the  anterior  superior  spine  ;  the  limb  is 
grasped  at  the  knee  with  the  right  hand. 

Flexion  is  gently  produced  until  the  commencing  tilting  of  the  pelvis 
shows  that  further  movement  in  this  dii'cction  is  prevented  by  muscular 
spasm.  The  number  of  degrees  travelled  by  the  thigh  ought  to  be  noted, 
as  it  represents  the  amount  of  flexion  permitted  by  the  hip-joint. 

Abduction  and  adduction  are  estimated  by  a  similar  test  of  lateral 
movement.  The  child  is  now  turned  upon  its  face,  and  the  movements 
of  rotation  and  hyperextension  are  investigated.  In  early  disease  of  the 
joint  rotation  is  the  first  movement  to  become  limited  by  muscidar  spasm, 
and  therefore  great  care  must  be  taken  in  its  examination.  The  movement 
is  best  performed  by  flexing  the  knee  to  a  right  angle,  grasping  the  sole  of 


HIP-JOINT  DISEASE  215 

the  foot  with  the  right  hand,  and  laying  the  pahu  of  the  left  hand  upon 
the  sacrum  in  such  a  way  that  the  fingers  can  investigate  the  right  trochanter 
and  the  thumb  the  left.  With  the  right  hand  movements  of  rotation, 
internal  and  external,  are  performed  on  each  joint.  If  muscular  spasm 
is  present  it  is  readily  appreciated  by  the  sudden  arrest  of  the  movement, 
the  involuntary  contraction  of  the  gluteal  muscles,  and  the  rocking  of  the 
pelvis  if  further  movement  is  attempted. 

Hyperextension  is  estimated  by  fixing  the  pelvis  with  the  open  left 
hand,  bending  the  knee  to  a  right  angle,  grasping  the  ankle  with  the  right 
hand,  and  steadily  Kfting  the  whole  limb.  Normally  the  degree  of  hyper- 
extension ought  to  amount  to  30  degrees. 

Nothing  is  to  be  gained  by  the  investigation  of  circumduction,  and  as 
any  estimation  of  it  is  accompanied  by  intense  pain,  its  examination  should 
never  be  pursued. 

Measurements  of  Limb  and  Displacements.— Estimations  are 
required  of  the  amount  of  real  or  apparent  lengthening,  of  real  or  apparent 
shortening,  of  the  degrees  of  flexion,  abduction,  or  adduction,  and  of  the  cir- 
cumference of  the  limb.  To  measure  these  amounts,  certain  landmarks  are 
recognised  and  marked.  They  are  the  anterior  superior  spines,  the  internal 
malleoli,  the  posterior  superior  angles  of  the  trochanters,  the  tuberosities  of 
the  ischia,  and  the  umbilicus. 

Real  lengthening  may  be  said  for  all  practical  purposes  never  to  occur. 
Cases  have  been  recorded  in  which,  from  stimulation  of  an  epiphysis  by 
neighbouring  disease,  limbs  have  increased  in  length.  If  it  is  present,  its 
amount  is  estimated  by  comparing  the  measurements  upon  each  side  between 
the  anterior  superior  spine  and  internal  malleolus.  Apparent  lengthening 
is  associated  with  abduction  and  tilting  downwards  of  the  pelvis  upon  the 
affected  side.  Its  estimation  is  made  by  measuring  the  distance  from  the 
umbilicus  to  the  internal  malleoli  upon  both  sides. 

Real  shortening  is  estimated  by  the  comparative  measurements  from 
anterior  superior  spine  to  internal  malleolus.  The  various  causes  which 
may  give  rise  to  shortening  have  been  already  mentioned.  Apparent 
shortening  depends  upon  adduction  and  upward  tilting  of  the  pelvis,  and  it 
is  measured  by  the  umbilico-malleolar  line. 

Estimation  of  Flexion. ^—'Hhia  is  estimated  by  Kingsley's  ^  method  in 
the  following  manner  :  The  patient  lies  on  his  back  on  a  table,  while  the 
surgeon  lifts  the  limb  until  the  lordosis  disappears  and  the  pelvis  lies  in 
normal  relation  to  the  trunk.  A  measurement  is  taken  from  the  table 
along  the  thigh  for  any  distance,  following  the  line  of  the  femur,  and  from 
the  extremity  of  this  measurement  a  vertical  line  is  dropped  to  the  table. 
The  exact  length  of  both  lines  is  noted.  The  decimal  fraction  obtained  by 
dividing  the  length  of  the  vertical  line  by  the  length  of  the  line  measured 
along  the  limb  will  give  the  sine  of  the  angle  between  the  limb  and  the 
table.  By  consulting  a  book  of  mathematical  tables  the  exact  size  of  the 
angle  can  be  estimated.  Kingsley  measures  a  constant  length  of  21  inches 
1  G.  L   King.sloy,  Boston  Med.  and  Surg.  Journ.,  .hi\y  5,  1888. 


216 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


along  the  thigh,  and  publishes  a  table  showing  the  angle  corresponding  to 
the  length  of  each  vertical  line  from  1  to  24  inches. 


Kingsley's  Table 


Inches. 

Degrees. 

Inches. 

Degrees. 

Inches. 

Degrees. 

Inches. 

Degrees. 

05 

1 

6-5 

IG 

12-5 

31 

18-5 

50 

1-0 

2 

7-0 

17 

13-0 

33 

190 

52 

1-5 

3 

7-5 

19 

13-5 

34 

19-5 

54 

20 

4 

8-0 

20 

140 

36 

20-0 

56 

2-5 

6 

8-5 

21 

14-5 

37 

20-5 

58 

30 

7 

9-0 

22 

15-0 

39 

21-0 

60 

3-5 

9 

9-5 

24 

15-5 

40 

21-5 

63 

4-0 

10 

100 

25 

16-0 

42 

22-0 

67 

4-5 

11 

10-5 

27 

16-5 

43 

22-5 

70 

5-0 

12 

11-0 

28 

17-0 

45 

23-0 

75 

55 

14 

11-5 

29 

17-5 

47 

23-5 

80 

60 

15 

120 

30 

18-0 

48 

240 

90 

Estimation  of  Abduction  and  Adduction. — The  degree  of  these  deformities 

is  estimated  by  Lovett's  ^  method.  With 
the  patient's  legs  lying  parallel,  measurements 
are  taken  from  the  anterior  superior  spine 
to  the  internal  malleolus  upon  each  side, 
and  similarly  from  the  umbilicus  to  the  in- 
ternal malleoli.  By  these  means  the  amount 
of  real  and  the  amount  of  apparent  shorten- 
ing are  estimated.  A  further  measurement 
is  taken,  namely,  the  distance  between  the 
anterior  superior  spines.  If  the  apparent 
shortening  is  greater  than  the  actual  shorten- 
ing, the  displacement  in  the  limb  is  one  of 
adduction ;  if  the  apparent  shortening  is 
less  than  the  real  shortening,  the  limb  is 
abducted.  In  order  to  make  the  calculation 
of  the  degree  of  abduction  or  adduction, 
two  figures  are  required — the  difference  ia 
inches  between  the  real  and  the  apparent 
and  the  distance  between  the 
The  further  esti- 


FlG.  97. — The  amount  of  ailiiuction 
which  may  exist  in  liip-joiut 
disease.  To  illustrate  the  degree 
of  adduction,  the  anterior  supe- 
rior spines  have  been  brought 
to  the  same  level. 

anterior  superior  spines 
mation  is  made  from  Lovett's  table  : 


shortening, 


1  Lovett,  Boston  Med.  and  Surg.  Journ  ,  March  8,  1888. 


[Table 


HIP-JOINT  DISEASE 
Lovett's  Table 


217 


Distance  between  the  Anterior  Sup 

erior 

Spine- 

in  Indies. 

3. 

3i. 

4. 

4i. 

5. 

5i. 

6. 

61. 

7. 

7i. 

8. 

8i. 

9. 

9i. 

10. 

11. 

12. 

13. 

i 

5° 

4° 

4° 

3° 

3° 

2° 

2° 

2° 

2° 

2° 

2° 

2° 

1° 

1° 

1° 

r 

1° 

1° 

0 

i 

10 

8 

7 

6 

5 

5 

4 

4 

4 

4 

4 

4 

4 

3 

3 

3 

3 

2 

J 

14 

12 

11 

10 

8 

8 

7 

7 

6 

6 

5 

5 

5 

4 

4 

4 

3 

3 

P. 

1 

19 

17 

14 

13 

11 

10 

9 

9 

8 

7 

7 

7 

6 

6 

6 

5 

5 

4 

<! 

li 

25 

21 

18 

16 

14 

13 

12 

11 

10 

9 

9 

8 

8 

7 

7 

7 

6 

6 

1^ 

H 

30 

25 

22 

19 

17 

15 

14 

13 

12 

12 

11 

10 

10 

9 

9 

8 

7 

7 

^■1 

If 

34 

30 

26 

23 

20 

18 

17 

15 

14 

13 

13 

12 

11 

10 

10 

9 

8 

8 

II 

2 

42 

35 

30 

26 

23 

21 

19 

18 

16 

15 

14 

14 

13 

12 

12 

10 

10 

9 

SM 

2i 

40 

34 

30 

26 

24 

21 

20 

19 

17 

16 

15 

14 

14 

13 

12 

11 

10 

2i 

39 

34 

29 

27 

24 

22 

21 

19 

18 

17 

16 

15 

14 

13 

12 

11 

"S 

2| 

38 

32 

29 

27 

25 

23 

21 

20 

19 

18 

17 

16 

14 

13 

12 

3 

42 

35 

32 

29 

27 

25 

23 

22 

21 

19 

18 

18 

16 

14 

13 

o 

B 

3i 

39 

36 

32 

30 

27 

26 

25 

22 

21 

20 

19 

17 

15 

14 

34 

40 

35 

33 

30 

28 

26 

24 

23 

22 

21 

19 

17 

16 

3} 

38 

35 

32 

30 

28 

26 

25 

23 

22 

20 

18 

17 

4 

42 

38 

35 

32 

30 

28 

26 

25 

23 

21 

19 

18 

These  estimations  and  measurements  are  important,  because  the  question 
of  diagnosis  may  occasionally  depend  upon  their  results. 

The  Investigration  of  Abscess  Formation. — The  tendency  to  the 
formation  of  abscesses  in  hip  disease  is  considerable,  and  the  condition  must 
be  looked  for  in  every  examination.  Abscesses  are  in  the  majority  of  cases 
primarily  intra-articular,  but  extracapsular  ones  may  develop  from  bone  foci 
lying  outside  the  attachments  of  the  ligaments.  When  the  pus  has  originally 
formed  within  the  joint,  it  usually  penetrates  through  the  weakest  part 
of  the  capsule  at  a  point  upon  the  posterior  inferior  quadrant.  Having 
gained  the  periarticular  soft  tissues,  it  may  take  up  various  positions. 

(1)  It  may  pass  outwards  beneath  the  attachment  of  the  rectus  femoris 
muscle,  and  appear  on  the  thigh  at  the  anterior  border  of  the  great  trochanter, 
or  more  anteriorly  at  the  outer  side  of  the  sartorius  muscle. 

(2)  It  may  extend  inwards,  and  appear  as  a  cold  abscess  among  the 
attachments  of  the  adductor  muscles  at  the  inner  side  of  the  thigh. 

(3)  It  may  pass  backwards,  often  along  the  course  of  the  internal  circum- 
flex artery,  appearing  at  the  posterior  edge  of  the  great  trochanter  or  the 
lower  border  of  the  gluteus  niaximus. 

(4)  It  may  travel  along  the  sheath  of  the  psoas  and  point  above  Poupart's 
ligament,  or  it  may  pass  over  the  brim  of  the  pehis  into  the  abdominal 
cavity . 

(5)  When  the  disease  is  markedly  acetabular,  tlie  floor  of  that  structure 
may  be  penetrated,  and  an  abscess  appear  upon  the  inner  surface  of  the 
bone  which  is  palpable  per  rectum. 

(6)  By  gravity  and  by  the  following  of  fascial  and  intermuscular  planes, 
pus  may  travel  a  considerable  distance,  and  become  apparent  at  a  point 
very  remote  from  its  site  of  origin. 

Even  when  an  abscess  is  not  actually  apparent  its  presence  may  be 


218  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

suspected  by  an  increase  in  general  symptoms,  more  especially  an  increased 
swing  in  temperature. 

X-Ray  Examination.  —  By  a  radiographic  examination  certain 
information  becomes  available  regarding  the  joint  cavity,  the  synovial 
membrane,  the  bones,  and  the  soft  parts  around. 

The  Joint  Cavity. — Attention  should  be  directed  to  the  space  which 
exists  between  the  head  of  the  femur  and  the  surface  of  the  acetabulum. 
If  this  space  is  much  increased,  and  there  is  apparently  a  displacement 
outwards  of  the  femoral  head  from  the  pelvic  girdle,  it  probably  means  an 
accumulation  of  fluid  within  the  joint  cavity.  Lying  within  the  cavity 
osseous  debris  and  small  sequestra  may  be  apparent. 

The  Synovial  Membrane. — When  the  synovial  membrane  is  diseased, 
it  is  often  possible  to  delineate  its  thickened  outline  at  the  points  where  the 
thickening  is  greatest,  namely,  the  synovial  reflexions.  Sometimes  localised 
patches  may  appear  specially  prominent  with  disease.  The  synovial  outhne 
must  not  be  mistaken  for  that  of  muscles  and  tendons  around  the  joint. 

The  Bones. — There  may  be  changes  in  the  gross  anatomy  of  the  bones 
or  in  their  intimate  structure.  The  derangements  of  gross  anatomy  may 
include  such  changes  as  separation  of  the  epiphysis,  a  tuberculous  coxa  vara, 
or  an  actual  pathological  dislocation.  The  more  intimate  bone  structures 
show  different  changes  in  dift'erent  stages  of  the  disease.  In  early  synovial 
disease  the  passage  of  the  rays  is  less  free  than  in  a  healthy  hip,  and  the 
bony  outline  appears  indistinct  and  hazy.  Watson  Cheyne  believes  that- 
this  blurring  is  the  result  of  a  pretuberculous  thickening  of  the  bony  trabe- 
culae.  It  is  more  likely  the  result  of  the  increased  thickening  and  vascularity 
at  the  synovial  reflexion,  with  a  correspondingly  greater  resistance  to  the 
passage  of  the  rays,  and  therefore  a  blurring  of  the  bony  outline.  Changes 
become  apparent  to  the  X-rays  at  the  edges  of  the  articular  cartilages, 
more  especially  that  covering  the  head  of  the  femur.  The  free  edges  of  the 
cartilage  show  a  pitted,  worm-eaten  appearance.  With  more  extensive 
disease,  the  joint  outline  is  altogether  altered.  The  head  of  the  femur 
becomes  eroded  and  irregular,  areas  of  disease  appear  in  the  underlying 
bone,  and  the  head  may  appear  displaced  at  its  epiphyseal  attachment. 
The  outline  of  the  acetabulum  becomes  irregular,  and  a  perforation  into  the 
pelvis  may  be  apparent. 

The  Soft  Parts. — A  cold  abscess  becomes  demonstrable  among  the  soft 
parts  as  a  clear  area  of  increased  resistance  to  the  X-rays.^ 

Diagnosis 

Absolute  Dlagrnosis. — What  are  the  points  which  lead  one  to  make  the 
diagnosis  of  hip-joint  disease  ? 

The  History. — The  history  is  essentially  chronic,  it  may  have  existed  for 
months  before  it  comes  under  the  care  of  the  surgeon.  It  is  the  history  of  a 
disease  which  is  confined  to  a  single  joint,  and  further  there  is  a  steady  and 

'  These  remarks  are  in  terms  of  the  negative. 


HIP-JOINT  DISEASE  219 

progressive  increase  in  the  symptoms  and  signs.  But  it  is  ou  the  revelations 
of  physical  examination  that  one  bases  one's  diagnosis. 

The  Attitude  of  the  Limb. — This  is  extremely  suggestive — the  early  flexion, 
abduction,  and  eversion  ;   the  late  flexion,  adduction,  and  internal  rotation. 

The  Gait. — The  gait  of  a  fully  established  case  is  typical  of  the  disease, 
more  especially  the  alternate  long  step  and  short,  the  bending  of  the 
joints  and  the  flexion  of  the  toes. 

The  Joint  Outline. — Information  gained  from  this  is  more  confirmatory 
than  diagnostic.  Valuable  signs  will  be  found  in  the  wasting  of  the  buttocks, 
and  the  changes  in  the  gluteal  and  groin  folds. 

Movements  of  the  Joint  and  Muscular  Spasm. — Limitation  of  movement 
and  muscular  spasm  are  interdependent,  and  from  a  diagnostic  point  of  view 
they  are  by  far  the  most  valuable  of  all  physical  signs.  Of  the  various  move- 
ments which  are  limited,  one  attaches  most  importance  to  rotation,  for  the 
reason  that  it  is  usually  the  first  to  be  interfered  with. 

Deformities  of  the  Limb. — In  all  probability  the  diagnosis  will  have  been 
made  before  this  becomes  apparent.  In  late  cases  of  the  disease  it  shows 
striking  features.  Flexion  is  not  pathognomonic,  as  it  is  merely  a  position 
of  rest,  and  one  which  is  induced  by  a  wide  variety  of  diseases.  The  displace- 
ments of  abduction,  adduction,  external  and  internal  rotation  are  of  nuich 
more  significance. 

X-Ray  Examination. — The  changes  of  early  hip-joint  disease  may  be 
practically  imperceptible  in  the  X-ray  plate.  The  first  feature  to  make  its 
appearance  will  be  the  blurring  and  indistinctness  of  the  femoral  epiphysis. 
In  the  later  stages  X-rays  are  not  so  much  a  diagnostic  aid  as  a  means  of 
telling  one  the  extent  and  limitation  of  the  disease. 

Differential  Diagnosis. — The  following  conditions  may  require  to  be 
excluded  : 

Local  Irritation.  ImtaiAon  or  disease  of  the  genitals  may  produce 
persistent  flexion  of  the  thigh  and  considerable  pain  on  movement,  and  in 
young  girls  vaginitis  may  produce  signs  which  bear  a  very  close  resemblance 
to  hip  di.sease.  The  causes  of  the  irritation  are  apparent  on  inspection,  and 
with  their  cure  the  hip  symptoms  disappear. 

Acute  Adenitis. — Associated  with  this  there  is  always  a  certain  degree 
of  flexion,  but  there  is  no!\e  of  the  muscular  spasm  of  hi))-joint  disease," and 
further  tiie  enlarged  groin  glands  are  sufficiently  obvious. 

Local  Injury. — Injury  to  the  joint,  often  quite  trivial  in  degree,  may 
cause  congestion  of  the  epiphy.sis  and  some  effusion  into  the  joint  cavity. 
The  resulting  symptoms  may  resemble  hip-joint  disease  in  so  far  as  they  are 
those  of  a  limp,  pain,  and  discomfort,  but  they  are  purely  temporary,  and  at 
the  end  of  a  week  or  two  they  have  disappeared. 

Anterior  Poliomyelitis. — The  intioduitory  stages  of  infantile  paralysis 
may  be  associated  with  local  pain  in  tlic  affected  limb.  Any  difficulty  in 
diagnosis  is  temporary,  and  it  is  cleared  up  by  the  onset  of  paralysis. 

Acute  Arlltritis  and  Epijihysilis. — This  is  not  unconimon  in  young 
children  as  a  sequel  to  the  exanthemata,  pneumonia,  or  diphtheria.     It  may 


220  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

be  distinguished  from  tuberculous  disease  by  the  sudden  onset  of  symptoms, 
by  the  high  fever  and  severe  constitutional  disturbance,  and  by  the  frequency 
with  which  several  joints  are  involved. 

Rheumalism. — Rheumatism  is  usually  of  sudden  onset.  It  is  always 
migratory  in  character  and  accompanied  by  fever.  In  children  it  is  some- 
times confined  to  a  single  large  joint,  and  for  a  time  its  diagnosis  may  be 
doubtful.  In  a  questionable  case  salicylates  should  be  administered  ;  a 
rheumatic  joint  is  relieved,  a  tuberculous  joint  is  not  affected. 

Lumbar  Pott's  Disease. — The  first  symptom  of  this  condition  may  be  a 
limp  and  restriction  of  movement  in  one  leg.  This  is  due  to  an  infiltration 
of  the  psoas  muscle  with  tuberculous  disease  and  an  irritation  and  con- 
traction of  its  fibres.  It  is  recognised  by  the  presence  of  rigidity  in  the 
lumbar  spine,  and  by  the  fact  that  the  only  movement  limited  in  the  hip- 
joint  is  one  of  extension.  It  may  also  be  excluded  by  the  distribution  of 
superficial  pain  (page  145). 

Knee-joint  Disease. — It  is  essential  to  draw  attention  to  the  fact  that 
hip- joint  disease  is  often  associated  with  the  presence  of  pain  referred  to  the 
knee.  Examination  will  show  which  part  is  affected.  It  is  a  rule  well  worth 
remembering,  "  In  every  case  of  painful  hip  examine  the  spine,  and  in  every 
case  of  painful  knee  examine  the  hip." 

Codoa  Vara. — This  distortion  of  the  neck  of  the  femur  may  lead  to 
difficulties  and  errors  in  diagnosis.  The  signs  which  induce  confusion  are 
those  of  shortening  and  limping.  A  diagnosis  should  be  made  by  examination 
of  the  movements.  In  coxa  vara  either  the  movements  are  imiformly  free 
or  abduction  alone  is  limited  ;  in  tuberculous  disease  of  the  joint  there  is  a 
general  Hmitation. 

Hysterical  Joint  Affection. — Confusion  with  this  condition  arises  more 
commonly  at  a  later  life-period,  but  before  puberty  nervous  children  may 
simulate  tuberculous  disease  by  a  condition  of  joint  sensitiveness  with 
lameness  and  pain.  The  characteristics  of  the  functional  disorders  are  the 
variability  of  their  intensity  and  their  inconsistency. 

Periarticular  Disease  which  has  not  yet  involved  the  Joint. — Clinically  this 
is  suggested  by  a  symptomatology  which  resembles  tuberculous  joint  disease, 
and  yet  on  physical  examination  the  typical  muscidar  rigidity  is  not  shown. 
The  most  reUable  of  all  the  methods  of  physical  examination  is  the  limitation 
of  the  movements  of  rotation.  Limitation  of  these  is  strongly  in  favour  of 
the  joint  being  involved. 

Perinephritis  and  Appendicitis. — These  have  been  mistaken  for  hip 
disease  because  of  the  psoas  contraction  which  they  produce.  They  are 
distinguished  by  their  history  and  by  the  limitation  of  movement  being 
restricted  to  a  single  manoeuvre — that  of  extension. 

Prognosis 

Functional  Prognosis. — Cure  may  result  with  a  complete  recovery  of 
usefulness  and  movement.     This  is  exceptional ;   usually  there  is  a  varying 


HIP-JOINT  DISEASE  221 

amount  of  limitation  of  movement,  and  quite  often  there  is  complete  anky- 
losis. The  functional  result  depends  upon  four  factors — (1)  the  condition  of 
the  disease  when  it  first  came  under  treatment ;  (2)  the  thoroughness  and 
efficiency  of  the  treatment  which  has  been  adopted  ;  (3)  the  severity  of  the 
disease  in  the  course  which  it  has  run  ;  (4)  the  resistance  of  the  individual 
whom  it  has  attacked. 

Length  of  Titne  under  Treatment. — The  early  discontinuance  of  treatment 
is  a  serious  mistake  ;  relapses  are  liable  to  occur,  and  the  relapse  is  frequently 
worse  than  the  original,  disease.  Treatment  must  be  continued  until  the 
joint  is  able  to  bear  a  considerable  amount  of  weight  and  strain  without  pain 
or  muscular  spasm  resulting.  Mechanical  treatment  must  be  continued  for  a 
long  period  after  all  active  symptoms  have  disappeared.  Two  years  at  least 
are  necessary  to  produce  a  cure. 

Life  Prog'nosis. — Actual  statistics  of  the  mortality  of  hip  disease  are 
not  very  reliable.  It  of  course  varies  widely  and  in  different  sections  of  the 
community  ;  under  efficient  treatment  and  proper  siuroundings  it  is  certainly 
not  high.  The  mortahty  is  due  almost  entirely  to  the  immediate  or  the 
remote  effect  of  abscess  formation.  This  is  well  illustrated  by  the  statistics 
of  Bruns.  He  showed  that  the  mortahty  in  non-suppurative  cases  was 
23  per  cent,  while  in  cases  in  which  suppuration  was  present  it  amounted  to 
52  per  cent.  Wagner  ^  foimd  at  Tiibingen  that  the  mortality  amounted  to 
40  per  cent.  At  Heidelberg,  according  to  Huismans,^  it  was  46-6  per  cent 
in  non-operative  cases  and  58  per  cent  in  operative  cases.  The  mortality 
among  the  patients  in  German  cliniques  is  imdoubtedly  much  higher  than  it  is 
among  the  same  class  of  patient  in  this  country  and  America.  In  288  cases 
treated  at  the  Hospital  for  Ruptured  and  Crippled,  New  York,  the  death-rate 
was  12-5  per  cent  (Gibney).^  And  m  this  country  the  average  mortality 
varies  from  10  to  18  per  cent. 

Death  results  from  a  variety  of  causes.  The  most  common  are  :  (1) 
miliary  tuberculosis  ;  (2)  tuberculous  meningitis  ;  (3)  pulmonary  tubercu- 
losis ;  (4)  waxy  disease  ;  (5)  exhaustion  ;  (G)  intercurrent  disease.  It  is 
believed  that  operative  interference  is  the  predisposing  cause  of  general 
tuberculosis  and  tuberculous  meningitis.  Statistics  do  not  bear  out  this 
assertion.  It  is  estimated  that  75  per  cent  of  the  death-rate  is  directly  or 
indirectly  due  to  suppuration. 

Treatment 

General  Treatment 

The  improvement  of  hip  disease  by  sunshine  and  fresh  air  is  of  the  utmost 
importance.  Food,  sunlight,  and  healthy  environment  are  the  first  con- 
siderations, and  by  them  is  the  inherent  resistant  force  increased.  A  cure 
very  largely  depends  upon  the  wise  oversiglit  and  management  of  these 

'  VVivgnoi-,  Beitr.  z.  hlin.  Chir.,  1895,  Bd.  .xiii. 

'^  Huismans,  Zcilschr.  J.  orthop.  Chir.  Bd.  vii.  H.  2  and  3. 

'  Gibnoy,  New  York  Medical  Journal,  July  and  August  1877. 


222  TUBERCULOSIS  OF. THE  BONES  AND  JOINTS 

general  factors.     For  a  discussion  of  this  portion  of  the  treatment  the  reader 
is  referred  to  page  64. 

Local  Treatment 

To  increase  the  practical  interest  the  local  treatment  will  be  considered 
in  the  sequence  in  which  it  is  actually  employed.     It  may  be  divided  into  : 

1.  Treatment  for  the  rehef  of  acute  symptoms. 

2.  Fixative  or  recumbent  treatment. 

3.  Ambulatory  treatment. 

4.  Convalescent  treatment. 

5.  Treatment  of  deformities. 

6.  Treatment  of  complications. 

7.  Operative  treatment. 

(1)  Treatment  for  the  Relief  of  Acute  Symptoms 

When  the  patient  is  first  brought  to  the  surgeon  it  is  common  to  find 
that  the  child's  leading  signs  are  those  of  pain  in  the  joint,  muscular  spasm, 

and  flexion  of  the  diseased  hip. 
It  ought  to  be  one's  first  duty 
to  reUeve  these,  and  the  best 
method  with  which  to  gain 
relief  is  extension  by  weight- 
and  pulley.  The  child  is  put  in 
a  bed  which  has  been  specially 
prepared  for  extension  by  the 
insertion  of  a  firm  mattress.  It 
is  well  to  control  the  body  by 
means  of  some  variety  of  double 

Kl..  9S.-Si,nple  traction  applied  iu  the  treat.neut         ^P'"!*"    ,     ^      Hamilton's      Or      a 

of  hipjoiut  disease.  Bryant's  is  the  best,  but  in  the 

event  of  these  not  being  avail- 
able there  is  no  great  disadvantage  experienced.  Extension  strapping  is 
applied  to  the  diseased  limb  (for  method  see  p.  101),  and  a  stirrup  and  weight 
are  attached  to  the  end  of  the  extension  tapes.  The  amount  of  weight  used 
varies  according  to  the  age  and  the  muscularity  of  the  child.  A  more 
complete  extension  is  obtained  by  raising  the  foot  of  the  bed.  Extension 
apphed  in  this  way  usually  gives  most  rapid  relief  to  the  distressing 
symptoms.  If  it  is  found  that  the  pain  is  not  reheved  an  explanation  must 
be  sought,  and  it  is  one  of  two :  it  may  be  due  to  an  error  in  the  amount 
of  weight  used,  too  much  or  too  little — the  error  is  more  frequently  the 
former  ;  or  it  may  be  the  result  of  an  imperfect  separation  of  the  articular 
surfaces.  When  the  latter  is  the  fault  it  is  often  remedied  by  combining 
the  extension  in  the  long  axis  of  the  limb  with  an  extension  parallel  to  the 
axis  of  the  neck  of  the  femur.  This  lateral  traction  is  carried  out  by  passing 
a  bandage  round  the  thigh  at  the  upper'  end  of  the  femur  ;  the  ends  of  the 


HIP-JOINT  DISEASE 


223 


bandage  are  connected  with  a  weight  hanging  over  the  side  of  the  bed. 
Traction  is  thus  produced  in  the  axis  of  the  neck  of  the  femur.  Counter 
extension  is  secured  by  passing  a  bandage  round  the  pelvis  upon  the  diseased 
side  and  connecting  it  to  a  weight. 

When  flexion  or  the  deformities  of  abduction  or  adduction  are  present 
an  alteration  miist  be  made  in  the  usual  method  of  extension.  The  traction 
must  not  be  indiscriminately  applied  in  the  position  which  the  limb  ought 
to  occupy,  but  it  should  be  applied  at  first  in  the  axis  of  the  deformity. 
Gradually  this  axis  is  brought  nearer  and  nearer  to  the  healthy  one  until 
the  deformity  has  disappeared.  Of  course  such  a  correction  of  the  deformity 
presupposes  that  simple  muscular  spasm  is  the  cause  of  the  occurrence. 
Extension  is  of  comparatively  little  use  when  there  is  contraction  of  liga- 


Flti.  99.  —  Riglit-angled  traction  in  the  trfatiiifiit  of  hiji-joiut  disease. 

ments  and  of  fibrous  tissue.  At  the  end  of  some  weeks  of  weight-exten- 
sion the  signs  for  which  it  has  been  introduced  will  have  disappeared,  and 
the  further  stage  in  treatment  may  be  proceeded  with. 


(2)  Recumbent  Treatment 

Thomas  believed  that  as  long  as  a  joint  was  immobilised  it  was  in  a 
suitable  condition  for  progressive  cure.  It  has  been  asserted  that  complete 
fixation  of  a  joint  is  liable  to  lead  to  ankylosis.  If  the  joint  disease  is  early, 
ankylosis  will  certainly  not  occur  ;  and  if  the  changes  in  the  joint  are  so 
extensive  as  to  render  ankylosis  possible,  it  is  probably  the  best  thing  which 
could  happen  with  a  view  to  later  cure  as  a  result.  Therefore,  when  tlie  acute 
symptoms  of  pain,  spasm,  etc.,  have  disappeared,  the  joint  is  immobilised 
without  being  permitted  to  bear  any  weight.  In  the  Edinburgh  Children's 
Hospital  two  methods  for  seeming  com])Iete  fixation  are  in  general  use — 
they  are  the  long  ])last('r  baitdagc  and  tlie  Thomas  hip  splint. 

The  Long-  Plaster  Bandage.— In  out-patient  work  dealing  with  the 
poorer  classes  of   patients,  this  is  the  favourite  application.     It  has  the 


224 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


Fig.  100. — Tlie  long  plaster  bandage  applied  in  the 
treatment  of  liip-joint  disease. 


advantages  of  cheapness,  durability,  comfort,  and  absolute  fixation.     Its 

disadvantages  are  the  tendency  to  become  filthy  and  the  weight. 

Method  of  Amplication. 
— The  joint  is  in  a  suit- 
able condition  for  the  apph- 
catioii  of  the  plaster  when 
pam  and  spasm  have  been 
relieved  and  deformity  cor- 
rected. The  general  rules 
for  the  application  of  plaster 
are  followed  (see  page  70), 
and  the  casing  is  carried 
round  the  pelvis  and  down- 
wards to  above  the  ankle,  or 
to  include  the  foot.  It  is 
applied  in  a  position  of  slight 
abduction  and  flexion  at  the 
hip- joint  and  slight  flexion 
at   the  knee-joint.     As  the 

plaster  has  a  considerable   tendency  to  break  opposite  the  hip  and  knee 

joints,  these  parts  are  specially  strengthened  by  incorporating  in  the  plaster 

narrow  strips  of  aluminium — one  in  front  and   one  behind,  opposite  the 

hip-joint,  and  one  behind  the  knee-joint. 

The  Thomas  Hip  Splint. — This  method  of  fixation  one  usually  recom- 
mends in  private.     It  has   the  special  advantages 

of   lightness,  adaptability,  and   cleanliness.     When 

weighed  against  the  plaster  splint  it  possesses  the 

disadvantages  of  being  more  expensive  and  perhaps 

of  being  a  less  efficient  immobiliser.     The  splint  is 

made   as  follows  :    A  flat  piece  of  malleable  iron, 

I  inch  wide  and   ^^  of   an   inch   thick,  and  long 

enough  to  extend  from  the  lower  angle  of  the  scapula 

to  the  middle  of  the  calf,  forms  the  upright.     It  is 

fitted  to  the  body  of  the  patient,  passing  from  the 

lower  angle  of  the  scapula  in  a  perpendicular  line 

downward  over  the  lumbar  region,  across  the  pelvis, 

slightly  external  but  close  to  the  posterior  superior 

spine  of  the  ilium  and  the  prominence  of  the  buttock, 

along  the  course  of    the  sciatic  nerve  to  a  point 

slightly  external  to  the  centre  of  the  calf  of  the  leg. 

The  lumbar  portion  of  the  upright  must  be  a  plane 

surface,  on  no  account  must  it  be  bent  to  the  lumbar 

lordosis.      It  must,    however,    be   slightly  twisted 

upon  its  own  axis  at  the  junction    of   the   upper 

and  middle  thirds,  so  that  the  anterior  surface  of  the 

lower  part  may  look  slightly  outwards  to  correspond  to  the  contour  of  the 


iiiiiiiiiiif"^ 


Fio.  101. — Thomas  hip 
splint. 


HIP-JOINT  DISEASE  225 

buttock  and  the  thigh.  A  second  and  double  bend  is  made  in  the  upright 
at  the  point  where  it  passes  the  buttock,  so  that  the  thigh  part  lies  on  a 
slightly  higher  plane  than  the  body  part,  but  parallel  with  it.  To  the 
upright,  chest,  thigh,  and  leg  bands  are  fitted.  The  chest  band  is  of  hoop 
iron,  it  is  1^  inches  wide  and  -^  inch  in  thickness.  It  is  bent  into  an  oval  to 
fit  the  shape  of  the  chest,  but  a  space  of  about  4  inches  ought  to  exist  between 
its  anterior  extremities.  This  space  is  bridged  across  by  a  strap  adjustable 
to  metal  studs.  The  chest  band  is  riveted  to  the  upper  extremity  of  the 
brace,  so  that  a  third  of  its  length  shall  be  on  the  side  of  the  diseased  joint 
and  two-thirds  on  the  other.  The  thigh  and  the  leg  bands  are  also  of 
hoop  iron  ;  they  are  |  inch  wide  and  ^  inch  thick.  The  thigh  band  is 
equal  to  two-thirds  of  the  circumference  of  the  thigh,  and  is  fastened  to  the 
upright  at  a  point  1  or  2  inches  below  the  buttock.  The  calf  band  is 
equal  in  length  to  half  the  circumference  of  the  calf,  and  it  is  riveted  to  the 
lower  extremity  of  the  brace.  The  splint  is  wound  with  thin  boiler  felt, 
and  covered  wth  smooth  leather  sewn  together  upon  the  outer  side.  In 
fitting  the  splint  the  long  arm  of  the  chest  band  is  made  to  hug  the  body 


FlCi.  102. — The  Thomas  hip  spliut — .a  "  nurse  "  aud  abduction  wing  are  attached. 

closely,  while  the  short  arm  should  be  somewhat  away  from  it ;  the  thigh  and 
calf  bands  are  applied  to  the  limb.  The  splint  is  suspended  by  shoulder  straps 
attached  to  the  transverse  bar,  and  between  the  thigh  and  calf  bands  the 
splint  is  secured  to  the  limb  by  turns  of  a  domette  bandage.  The  splint  must 
be  heavy  and  strong,  and  it  is  eft'ectively  applied  when  a  furrow  appears  on  the 
buttock  directly  over  the  neck  of  the  femur.  Once  fitted  the  splint  is  only 
changed  at  infrequent  intervals.  To  prevent  any  possibility  of  the  child 
attempting  to  walk,  a  fiat  iron  bar  is  fastened  so  as  to  project  from  the  end 
of  the  splint.     This  bar  is  called  "  a  nurse." 

Complete  fixation  is  continued  for  at  least  one  year,  in  some  cases  for 
eighteen  months.  If  plaster  is  used  the  case  is  removed  and  reapplied  at 
intervals  of  three  months  during  this  period.  At  the  end  of  the  period  the 
joint  ought  to  be  well  on  its  way  towards  cure,  and  the  conditions  are 
favourable  when  there  is  absence  of  pain  and  muscular  spasm  and  no 
tendency  towards  a  deformity.  To  judge  of  this,  the  fixation  apparatus  is 
entirely  removed  for  about  three  days  -the  child,  of  course,  being  kept  in 
bed.  With  conchision  of  the  recumbent  treatment  the  ambulatory  treat- 
ment is  begun,  but  before  one  does  so  one  must  consider  another  method  by 
whicli  ti.xiition  uimv  he  secured. 

The  Traction  Hip  Splint.-  While  a  Thoma.s  hip  splint  and  the  plaster 
bandage  provide  immobilisation  of  the  part,  they  do  not  ensure  any  degree 
of  traction.     The  traction  hip  splint  affords  a  considerable  amount  of  fixation, 

15 


226 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


and  in  addition  it  provides  traction.  It  was  originally  introduced  by  Davis, 
and  modified  considerably  by  Taylor  and  Sayre.  Its  introducers  intended 
the  splint  to  be  used  as  a  means  of  ambulatory  treatment,  but  it  is  often 
employed  during  the  recumbent  period,  and  it  will  be  described  now.  It 
consists  of  an  upright,  an  adjustable  foot-piece,  a  waist-band,  and  leg  and 
perineal  bands.  The  upright  is  a  square  steel  rod  connecting  the  waist-band 
and  the  foot-piece,  and  it  extends  from  the  level  of  the  anterior  superior 
spine  to  a  point  about  3  inches  beyond  the  sole  of  the  foot.  It  may  be 
in  a  straight  line  or  it  may  be  bent  to  fit  the  curve  of  the  thigh  and  the  knee. 
The  lower  end  is  perforated  with  holes  for  the  attachment  of  the  adjustable 
foot-piece,  and  the  upper  end  is  flattened  out  into  a  small  oblong  plate  for 


Fig.  103.— Traction 
hip  splint. 


Fig.  104.— The  Ridlon  long 
traction  hip  .splint. 


Fio.  105.— The  Shaffer 
hip  splint. 


attachment  to  the  waist-band.  The  adjustable  foot-piece  is  forged  from  a 
piece  of  steel,  11  inches  long.  The  upper  end  is  flattened  into  an  oval 
and  the  projecting  sides  tinned  up  ;  to  clasp  the  upright,  it  is  perforated 
with  a  row  of  screw  holes.  In  the  lower  part  it  is  forged  |  inch  wide  and 
J  inch  thick  ;  |  inch  is  then  turned  over  at  the  end  at  a  sharp  right 
angle,  and  a  similar  angle  is  forged  2 J  inches  further  up  to  form  a  foot-piece. 
A  J-inch  hole  is  bored  in  the  turned-up  end,  h  inch  from  the  ground,  and 
one  in  the  upright  opposite  it  for  the  attachment  of  a  windlass  spindle. 
This  is  3|  inches  long  and  J  inch  in  diameter,  it  is  square  at  one  end  and 


HIP-JOINT  DISEASE 


227 


is  held  in  place  by  a  pin.  It  projects  beyond  the  outside  surface  of  the 
upright  for  h  an  inch.  Outside,  next  to  the  upright,  there  is  attached  to 
it  a  I -inch  ratchet  wheel,  which  is  controlled  by  a  spring  and  stop  fastened 
to  the  upright  by  pins.  The  projecting  end  of  the  spindle  is  made  square 
to  fit  a  clock  key.  The  centre  of  the  spindle  is  filed  half-way  through  on 
one  side  and  a  slot  cut  out  and  in  from  this  point  to  within  J    inch  of  the 

foot-piece  to  receive  the  webbing 
straps  of  the  extension.  The 
waist-band  is  of  flat  steel  1  inch 
wide.  The  posterior  half  is  1 
inch  longer  than  the  anterior 
half,  and  it  is  bent  in  a  more 
gradual  curve.  The  band  extends 
from  the  centre  of  the  outer 
surface  of  the  thigh  above  the 
trochanter  to  a  point  just  over 
the  opposite  anterior  superior 
spine.  It  is  riveted  to  the  upper 
end  of  the  upright,  and  it  is  in- 
clined at  20  degrees  to  the  horizon, 
the  posterior  end  being  higher. 
Buckles  are  fastened  to  the  lower 
edge  of  the  waist-band  for  the 
attachment  of  the  perineal  straps 
— there  are  two  in  front  and  two 
behind.  At  the  back  they  lie 
upon  each  side  half-way  between 
the  trochanter  and  the  posterior 
superior  spines.  In  front  they 
are  sufficiently  far  apart  not  to 
exert  any  pressure  upon  the  genitals.  To  the  end  of  the  posterior  arm  a 
belt  is  attached  to  complete  the  waist-band,  it  buckles  to  the  extremity  of 
the  anterior  arm. 

Leg  Bands. — There  are  generally  three  of  these  in  older  children  and 
two  in  small  ones.  They  are  situated  at  the  middle  of  the  thigh  and  the 
upper  third  of  the  calf.  They  extend  half  round  the  limb  and  the  circum- 
ference is  completed  by  a  strap. 

The  Perineal  Bands. — The  perineal  bands  are  of  webbing  covered  with 
Canton  flannel  and  padded  with  felt.  They  are  secured  to  the  buckles  of 
the  waist-belt  in  front  and  behind. 

The  Application  of  the  Splint. — Traction  is  made  upon  the  leg  by  adhesive 
plaster  in  any  of  the  methods  already  described.  The  lower  ends  of  the 
atlliesive  straps  terminate  in  tapes  which  |)r()ject  beyond  the  foot  for 
attachment  to  the  windlass  of  the  splint.  Tiie  s|)lint  is  applied  in  the 
following  inatiner  :  The  patient  lying  on  his  l)ack,  tiio  pelvic  band  is  adjusted 
and  strapped  about  the  body.     'J'he  perineal  bands  are  drawn  lirmly  into 


Fig.  10(i.— Tlio  .Judson  liip 
splint  with  periueiil  crutcli. 
Tlie  su.speniler  ami  p.itteu 
are  illustrated. 


Fig.  107.— The 
Judson  traction 
hip  splint. 


228  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

place,  so  that  pressure  on  the  upright  does  not  move  the  pelvic  band  from 
its  proper  position  just  above  the  trochanter.  The  brace  is  pushed  upwards 
against  the  resistance  of  the  pelvic  bands,  while  the  limb  is  at  the  same  time 
drawn  downwards  and  fixed  by  attaching  the  extension  straps  to  the  buckles 
at  the  end  of  the  adhesive  plasters.  Traction  is  applied  to  the  point  of 
tolerance  by  means  of  the  key.  The  splint  must  be  worn  day  and  night. 
The  perineal  bands  may  be  loosened  from  time  to  time  to  allow  for  bathing 
the  skin  with  alcohol  and  for  powdering,  but  while  this  is  being  done  manual 
traction  should  be  made  upon  the  limb  until  the  brace  has  been  readjusted. 
Considering  the  apparatus  as  a  fixation  splint  and  not  as  a  walking  brace 
(see  later)  it  has  distinct  advantages.  It  is  decidedly  comfortable,  it  ensures 
constant  and  effective  traction;  and  as  long  as  the  patient  remains  recumbent 
and  the  traction  is  continued,  there  is  good  practical  fixation. 

(3)  Ambulatory  Treatment 

Ambulatory  treatment  must  be  begun  gradually.  The  patient  at  first 
gets  up  for  a  short  time,  morning  and  evening,  and  that  period  is  extended 
from  time  to  time.  For  the  successful  conduction  of  ambulatory  treatment 
it  is  essential  that  the  hip-joint  should  be  fixed,  and  that  the  weight-bearing 
function  of  the  joint  should  be  reduced  to  a  minimum.  The  special  advaritage 
of  the  method  lies  in  the  fact  that  it  is  favourable  to  a  rapid  improvement 
in  the  patient's  general  condition,  for  he  is  now  able  to  spend  his  time  out 
of  doors  and  have  that  amount  of  exercise  which  tones  and  invigorates  his 
system. 

Methods. — Splints,  too  numerous  to  mention,  have  been  introduced 
at  one  time  and  another.  It  is  possible  to  mention  only  the  more  important. 
It  will  simplify  matters  to  describe  them  under  three  headings  :  {A)  The 
plaster  splint  and  its  modifications  ;  (B)  Thomas  splint  and  its  modifications ; 
(C)  The  traction  splint  and  its  modifications. 

{A)  The  Plaster  Splint  and  its  Modifications 

(1)  The  Long  Plaster  Spica  with  High  Boot  awl  Crutches. — The  plaster 
case  is  applied  in  the  usual  manner,  extending  around  the  pelvis  and  along 
the  leg  as  far  as  the  foot.  The  boot  used  on  the  healthy  foot  is  fitted  with 
a  patten  or  a  high  sole  of  such  a  height  that  when  the  patient  stands  erect 
the  foot  which  is  encased  in  plaster  is  swung  free  of  the  ground.  Crutches 
are  used  to  get  about  with.  If  one  were  asked  to  summarise  the  advantages 
of  this  splint  one  would  mention  its  cheapness,  the  simplicity  of  its  applica- 
tion, and  the  complete  fixation  which  it  afEords  to  the  joint.  It  has, 
however,  disadvantages,  which  are  very  considerable.  Its  weight  is  excessive 
and  the  majority  of  children  find  it  so  distressing  that  they  refuse  to  continue 
the  treatment.  The  second  disadvantage  is  that  of  discomfort ;  as  long 
as  the  patient  lies  recumbent  a  plaster  case  may  be  exceedingly  comfortable, 
but  when  the  erect  position  is  maintained  for  any  length  of  time  there  is 


HIP-JOINT  DISEASE 


229 


a  persistent  drag  upon  the  pelvic  girdle,  and  this  drag  soon  becomes  a  source 
of  annoyance. 

(2)  The  Short  Plaster  Spica. — This  is  sometimes  called  the  "  Lorenz  " 
splint.  It  is  used  in  the  Lorenz  Clinic  at  Vienna  as  the  routine  treatment  of 
hip  disease,  except  in  those  cases  which  cannot  bear  direct  weight  without 
pain  being  aroused.  Here  it  is  dis- 
cussed purely  as  a  means  of  ambu- 
latory treatment.  The  plaster  case 
is  applied  to  the  affected  limb  in  such 
a  way  that  it  fixes  the  limb  in  an 
attitude  of  slight  flexion  and  abduc- 
tion. The  plaster  is  carefully  moulded 
about  the  pelvis  and  thigh  ;  at  its 
lower  end  it  is  cut  away  immediately 
above  or  immediately  below  the 
knee.  Above,  it  rises  laterally  to 
below  the  iliac  crests,  anteriorly  to 
just  above  the  symphysis  pubis,  and 
posteriorly  it  passes  across  the  centre 
of  the  sacrum.  Crutches  and  a  high 
boot  upon  the  opposite  foot  are  used. 
In  mild  cases  the  splint  is  preferable 
to  the  heavy  long  splint.  It  pos- 
sesses the  common  advantages  of 
simplicity  and  cheapness,  and  in 
addition  it  is  by  comparison  con- 
siderably lighter.  It  has,  however,  by  no  means  the  same  power  of  fixation, 
and  for  that  reason  its  use  is  not  to  be  recommended  in  any  but  the 
mildest  and  most  advantageous  cases. 

(3)  The  Lorenz  Splint  with  Stilt. — In  the  treatment  of  the  more  acute 
cases  Lorenz  recommends  the  use  of  a  stilt  in  combination  with  the  short 
spica.  It  is  part  of  Lorenz's  plan  to  allow  his  patients  to  bear  weight  upon 
the  diseased  joint,  and  it  is  when  weight-bearing  induces  pain  that  he  advises 
the  use  of  his  stilt.  There  are  many  who  do  not  consider  that  weight-bearing 
ought  to  be  permitted  during  the  period  of  ambulatory  treatment,  and 
therefore  would  not  make  use  of  the  stilt  for  this  reason,  but  because  it 
improves  the  process  of  ambnlation.  The  stilt  consists  of  a  stirrup  of  steel 
which  projects  for  about  3  inches  beyond  the  sole  of  the  foot.  To  the 
upper  end  of  the  stirrup  semicircles  of  steel  are  attached,  and  these  are 
incorporated  in  the  plaster  above  the  region  of  the  knee.  The  patient 
walks  upon  the  lower  end  of  the  stilt,  the  foot  being  thus  carried  free  of  the 
ground.  The  weight  is  transmitted  along  the  side  of  the  stilt  to  the  ])laster 
and  thence  to  the  pelvic  girdle.  This  application  has  the  advantage  of 
making  locomotion  easier  for  the  patient,  and  when  the  short  spica  is  used 
as  the  fixation  agent  it  is  well  to  combine  the  stilt  with  it. 

(4)  The  Sh(jrt  Spica  with  the  Traction  Brace.     Whitman  was  the  first  to 


Fiu.  lOS.— Tlie 


spiL'a. 


230  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

recommend  the  combination  of  the  short  spica  bandage  vfith.  the  traction 
splint.  He  describes  how  he  had  been  taught  in  his  early  training  to  rely 
largely  for  treatment  upon  the  traction  splint.  He  later  became  somewhat 
dissatisfied  with  this  method,  as  he  found  that  while  it  usually  relieved 
pain  and  muscular  spasm  it  did  not  prevent  deformity  if  the  patient  was 
permitted  to  go  about.  The  deformity  most  commonly  produced  was  one 
of  flexion  and  adduction,  and  it  came  on  when  the  patient  was  allowed  to 
sit  up.  The  traction  splint  was  further  disappointing  in  so  far  that  during 
exacerbation  it  did  not  materially  relieve  the  pain.  Under  these  condi- 
tions it  was  found  that  acute  symptoms  might  be  relieved  and  deformity 
prevented  by  the  application  of  a  close-fitting  short  spica  bandage  extending 
from  the  middle  of  the  thorax  to  the  knee.  Over  this  the  traction  brace 
was  applied.  An  apparatus  is  thus  produced  which  combines  fixation, 
traction,  and  stilting,  a  high  boot  being  worn  on  the  healthy  foot. 


(B)  Thomas  Splint  and  its  Modifications 

(1)  Simple  Thomas  Splint  with  High  Boot  and  Crutches. — When  the 
simple  Thomas  splint  is  used  in  ambulatory  treatment,  weight-bearing  is 
removed  from  the  diseased  limb  by  fitting  a  patten  to  the  opposite  foot 
and  giving  the  patient  crutches.  In  this  country  it  is  probably  the  most 
common  appliance  used  at  this  period  of  treatment,  and  it  is  most  satis; 
factory.  When  used  during  the  ambulatory  period  the  splint  has  a  tendency 
to  rotate,  but  this  can  be  prevented  by  accurate  fitting.  The  liability 
which  there  is  to  the  development  of  the  lateral  distortions  of  abduction  or 
adduction  is  counteracted  by  the  use  of  opposite-sided  chest  bauds  (page  237). 

(2)  The  Short  Thomas  Splint. — This  is  a  modification  of  the  ordinary 
Thomas  in  which  the  vertical  portion  of  the  splint  ends  at  the  thigh  cross 
bar.  It  possesses  the  advantage  of  movement  at  the  knee,  rather  a  doubtful 
advantage,  as  the  knee  movement  is  only  gained  at  the  expense  of  diminishing 
the  fixation  of  the  hip.     It  should  only  be  used  as  a  convalescent  splint. 

(3)  The  Combined  Thomas  and  Traction  Splint. — Elsewhere  the  reasons 
for  the  introduction  of  the  combined  short  spica  and  traction  splint  have 
been  discussed.  The  combined  Thomas  and  traction  splint  was  produced 
to  meet  very  similar  indications.  To  the  pelvic  band  of  a  traction  spHnt 
a  lateral  thoracic  bar  is  attached,  reaching  upwards  in  the  axillary  line  to  a 
point  opposite  the  middle  of  the  scapula,  where  it  is  joined  to  a  metal  band 
encircling  the  chest.  Traction  is  secured  as  in  an  ordinary  traction  splint. 
The  splint  can  be  further  improved  by  substituting  for  the  perineal  bands 
of  the  traction  splint  a  ring  similar  to  that  used  in  a  Thomas  knee  splint. 
The  ring  is  fixed  to  the  lateral  bar  of  the  traction  splint,  and  it  affords 
excellent  fixation  to  the  pelvis. 


HIP-JOINT  DISEASE 


231 


(C)  The  Traction  Hip  Splint  and  its  Modifications 

(ff)  The  Simple  Traction  Splint. — The  simple  splint  has  been  already 
described  in  application  to  recumbent  treatment,  and  it  differs  in  no  respect 
when  used  as  an  ambulatory  splint.  When  the  apparatus  is  used  as  a  walking 
brace,  constant  traction  is  not  exerted,  for  the  traction  straps  alternately 
relax  and  tighten  as  the  body  weight  in  walking  alternately  falls  upon  and 
leaves  the  brace.  The  critics  of  the  brace,  therefore,  assert  that  it  exerts  a 
deleterious  pumping  action  upon  the  joint.  In  acute  cases  the  braced  limb 
is  made  pendent  by  using  a  high  sole  upon  the  opposite  foot  and  crutches. 
Treatment  by  the  long  traction  brace  has  been  called  "  The  American 
Treatment  of  Hip  Disease." 

(6)  The  Traction  Splint  combined  with  the  Short  Spica  has  been  already 
described  (page  229). 

(c)  The  Combined.  Traction  and  Thomas  Splint  has  also  been  described 
(page  230). 

(d)  Bradford  Hip  Splint. — This  form  of  apparatus  has  been  de\'ised 
for  the  purpose  of  fixing  the  hip  by  traction,  and  at 
the  same  time  overcoming  the  chronic  muscular 
spasm  at  the  joint.  It  consists  of  two  steel  rods, 
longer  than  the  affected  limb,  connected  below  by 
a  flat  steel  bar,  furnished  with  a  small  windlass 
attachment  to  produce  traction,  and  above  by  a 
ring  open  in  front.  This  ring  is  placed  obliquely 
upon  the  rods  so  as  to  fit  the  buttock  from  the 
tuber  ischii  to  above  the  great  trochanter.  To 
the  ring  near  the  top  of  the  inner  rod  a  bent 
steel  rod  is  welded  ;  it  passes  above  the  sym- 
physis and  under  the  perineum  of  the  healthy  side, 
and  should  be  long  enough  so  that  the  end  does 
not  press  into  the  buttock  when  the  patient  is 
seated.  The  limb  is  steadied  by  circular  leather 
straps,  and  traction  is  furnished  by  means  of 
adiicsive  plaster  straps  secured  to  the  windlass 
and  applied  to  the  hmb.  When  the  splint  is 
pr()])criy  applied  there  is  excellent  fixation  of  the 
hip-joint,  and  the  limb  is  held  well  abducted.  Tlie 
appliance  is  light  and  inexpensive,  and  it 
requires  no  special  skill  in  adjustment.  Locomo- 
tion is  made  possible  by  raising  the  sole  of  the 
opposite  boot,  and  if  necessary  crutches  are  adilod. 

Phelp.-<  Hip  Splint.-  To  this  form  of  hi])  splint 
Phelps  apjilied  the  principle  of  the  Thomas  ring. 
It    combines    fixation    with    traction,    and    the 

traction  is  a  doubles  one,  being  bt)th  vertical  and  lateral.     Tliere  is  a  lateral 
stay  running  from  the  axilla  to  beyond  the  foot,  and  the  lower  end  is  fitted 


Fl(i.  lOfl.^Hiailfoiii'.s  aliiluctiou 
s|ilint  for  tuliorouloiKs  disease 
ol  the  liip-joint. 


232 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


with  an  adjustable  foot-piece  and  traction  straps,  exactly  as  in  the  traction 
splint.  There  are  two  body  bands,  one  passing  round  the  chest  and  one 
round  the  pelvis.  They  are  of  steel  riveted  to  the  upright,  their  circum- 
ference being  completed  with  a  leather  strap  and  buckle.  Opposite  the 
hip-joint  a  Thomas  ring  is  fastened  oblii^iiely  to  the  upright  in  such  a  way 
that  it  supports  the  pelvis  passing  from  above  the  trochanter  to  beneath  the 
tuberosity  of  the  ischium.  The  leg  is  fastened  to  the  upright  by  a  semi- 
circular band  opposite  the  knee  and  one  round  the  ankle.  At  the  upper 
third  of  the  thigh  there  is  a  flat  leather  pad  which  presses  upon  the  inner  side 
of  the  limb,  and  is  fastened  to  the  upright  by  adjustable  cords  which  pass 

round  the  limb  to  the  upright  ;  by  means  of  this 
pad  lateral  traction  is  carried  out.  The  splint  is 
applied  to  the  limb  ;  vertical  extension  is  pro- 
cured by  fastening  adhesive  plasters  to  the  limb 
and  securing  their  ends  to  the  extension  buckles  ; 
lateral  extension  is  obtained  by  means  of  the 
pad  and  cord  just  mentioned.  WTiile  this  splint 
appears  excellent  in  theory  it  is  rather  disappoint- 
ing in  practice.  Its  vertical  traction  is  imperfect, 
and  the  lateral  traction  is  certainly  more  imagi- 
nary than  real.  However,  the  upright  and  the 
Thomas  ring  give  good  fixation. 

It  has  been  urged  against  splints  such  as  this, 
which  possess  an  upright  passing  beyond  the  hip 
to  the  chest,  that  the  fixation  which  they  afford 
is  ineffective  because  the  movements  of  the  trunk 
are  transmitted  to  the  joint.  This  is  not  true  of 
braces  which  do  not  extend  above  the  pelvis.  In 
practice  one  finds  that  motion  of  the  upper  part 
of  the  trunk  is  absorbed  as  it  were  in  the  flexible 
lumbar  region  of  the  spine  before  it  reaches  the 
joint.  The  chief  disadvantage  of  long  splints 
which  fix  the  hip  and  spine  appears  when  the 
down ;  such  a  manceuvre  becomes  impossible 
To  meet  the  difficulty  a  special  chair  is  used 

The  splinted 


Fig. 


110. — The  Phelps  traction 
hip  splint. 


patient    attempts    to  sit 

with  any  degree  of  comfort 

in  which  there  is  only  half  a  seat  and  that  for  the  sound  side. 

limb  remains  in  the  extended  position,  the  brace  resting  upon  the  floor. 

The  Bane  Hip  Splint. — Dane's  splint  is  a  combination  of  the  Thomas 
knee  splint  with  a  windlass  and  ratchet  for  extension  at  the  base,  and  with 
the  waist-band  of  a  traction  splint  fastened  to  the  top  above  the  ring.  It 
differs  from  the  Thomas  knee  splint  in  having  a  stouter  upright  on  the  outer 
side.  From  the  waist-band  there  is  no  perineal  band  upon  the  diseased 
side,  as  its  place  is  taken  by  the  ring.  Upon  the  healthy  side  there  is  a 
perineal  band  usually  in  the  shape  of  a  chain  covered  with  chamois  leather. 
Dane  later  modified  his  splint  by  altering  the  waist-band.  He  has  added  to 
it  a  second  posterior  pelvic  band,  which  is  carried  as  low  down  as  possible 


HIP-JOINT  DISEASE 


233 


over  the  sacrum.  A  firm  grasp  of  the  pelvis  is  thus  obtained,  and  move- 
ments of  the  hip-joint  are  in  large  measure  prevented.  It  is  an  excellent 
splint,  but  it  requires  care  in  adjustment  in  order  to  prevent  the  formation 
of  sores  in  the  perineum. 

The  Convalescent  Hip  Splint. — The  convalescent  hip  splint  is  a  form 
of  traction  splint,  which,  while  it  keeps  the  patient's  heel  off  the  ground, 
permits  him  to  walk  upon  his  toes.  The  traction  splint  is  easily  converted 
into  the  convalescent  type.  The  lower  end  is  cut  3  inches  from  the 
ground,  and  there  is  welded  to  the  lower  part  a  piece  long  enough  to  extend 
2  inches  below  the  sole  of   the  boot,  where   it  extends  into   a  bulbous   tip 


I''iii.  111. — Dane's  hip  splint. 


Fii:.   112.  — Convalescent  splint  witli  attach' 
nient  on  shoe. 


f  inch  in  diameter.  The  splint  should  extend  from  the  anterior 
superior  spine  to  \\  inches  beyond  the  bottom  of  the  heel,  the  foot  being  held 
at  right  angles.  If  desired  the  lower  end  of  the  splint  can  be  made  adjust- 
able with  screws.  The  bulbous  tip  may  be  covered  over  with  a  crutch 
rubber  to  prevent  slipi)ing.  A  modification  of  the  splint  is  made  by  attaching 
the  lower  end  to  the  sole  of  the  boot. 

Tubuhir  Hip  Splint. — For  children  under  five  years  of  age  Thornton  ' 
recommends  a  traction  splint  with  an  upright  of  steel  tubing,  because  it  is 
stifli'i-  and  lighter  than  a  small  steel  rod.     The  upright  consists  of  a  piece  of 

'  Thornton,  loc.  .sw;).  cil.  p.  1)72. 


234 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


steel  tubing  about  J  inch  in  diameter ;  to  its  upper  end  a  waist-band  is 
attached  as  in  a  single  traction  splint ;  into  the  lower  end  of  the  upright 
there  slides  a  rod,  which  carries  a  foot-piece.  Rotation  of  the  rod  in  the  tube 
is  prevented  by  fastening  a  pin  into  the  rod  through  a  slot  in  the  tube,  and 
vertical  movement  is  controlled  by  nuts  and  screws.  The  foot-piece  is  not 
provided  with  a  ^vindlass  but  with  buckles.  Extension  is  secured  with 
strapping  in  the  usual  way. 

The  Choice  of  an  Ambulatory  Splint.— It  is  difficult  to  recommend  any 
one  of  the  above-mentioned  ambulatory  splints.     One  must  judge  by  practical 


c;:^^ 


Fl«.  113.— The  tubular  liip 
splint  for  use  in  the  con- 
valescent treatment  of  hip- 
joint  disease. 


Fig.  114. — The  combination 
Ridlon  splint.  It  is  used 
in  hip-disease  with  much 
rotation,  and  in  hip  and 
knee  disease  of  the  same 
side. 


FiG.  115. — Combined  Thomas 
kuee  and  hip  splint  for 
use  in  hip -disease  and 
knee-disease  on  the  same 
side. 


experience,  and  it  is  only  this  which  will  guide  one  in  the  choice  of  splint 
for  an  individual  case.  One's  routine  practice  is  to  employ  a  Thomas  splint. 
If  pain  and  spasm  begin  to  reappear  one  either  returns  the  patient  to 
recumbency  and  weight  extension,  or  one  tries  the  substitution  of  a  traction 
splint  for  the  Thomas.  The  second  contra-indication  to  the  use  of  the 
Thomas  splint  is  the  tendency  to  a  deformity  in  the  shape  of  adduction, 
and  when  this  threatens  one  recommends  a  Bradford  abduction  splint. 


(4)  Convalescent  Treatment 

The    surgeon    often    experiences    considerable    difficulty    in    making 
up  his  mind  when   ambulatory  treatment  is  to  be  stopped.     In  deciding 


HIP-JOINT  DISEASE 


235 


this  point  it  must  be  insisted  that  the  ambulatory  treatment  shall  have 
been  continued  for  a  sufficient  length  of  time  to  enable  the  disease  to 
recover,  presupposing  that  it  is  of  the  ordinary  type  and  treated  under 
satisfactory  conditions.  If  there  have  been  no  symptoms  of  active  disease 
for  a  year  or  more,  and  if  muscular  spasm  is  absent,  one  may  test  the  joint 
by  removing  the  splint  at  night  to  ascertain  the  effect  of  simple  motion 
without  weight-bearing.  This  is  continued  for  about  one  month,  and  if 
at  the  end  of  that  time  free  movement  is  being  acquired  without  pain  or 
discomfort  some  form  of  walking  splint  may  be  fitted. 

Walking"  Splints. — Up  to  this  point,  while  the  patient  has  been  per- 
mitted to  walk  about,  no  direct  weight  has  been  borne  by  the  joint,  because 
care  has  been  taken  to  fit  the  opposite  boot  with  a  patten  and  to  provide 
the  patient  with  crutches.  In  this,  which  may  be  called  the  final  stage  of 
treatment,  while  a  certain  amount  of  support  is  given  to  the  joint,  some 
degree  of  weight-bearing  is  permitted  and  movements  are  encouraged 
within  certain  limits.  To  fulfil  these  indications  walking 
splints  are  in  use. 

Taylor's  Convalescent  Splint. — The  structure  of  the 
splint  is  easily  understood  by  reference  to  the  illustration. 
The  lateral  brace  is  jointed  at  the  knee,  and  it  is  so 
adjusted  that  it  is  slightly  longer  than  the  leg ;  the  heel 
does  not  touch  the  bottom  of  the  shoe.  The  weight  is 
therefore  partly  removed  from  the  foot,  and  borne  instead 
by  a  perineal  band  which  is  attached  to  the  upper  end  of 
the  splint. 

Convalescent  Lateral  Brace. — This  is  an  excellent  form 
of  walking  splint,  combining  lightness,  simplicity,  and 
cheapness.  A  lateral  brace  is  attached  above  to  a  pelvic 
band  and  to  a  perineal  crutch,  and  opposite  the  knee  the 
brace  is  jointed.  The  lower  end  of  the  splint  is  attached 
as  in  a  calliper  splint  to  the  sole  of  the  boot. 

There  are  other  forms  of  walking  splints,  but  the  above 
mentioned  are  very  satisfactory. 

As  the  strain  upon  the  joint  becomes  naturally  increased  it  is 
necessary  to  watch  carefully  for  any  return  of  muscular  spasm,  pain,  or 
increasing  limitation  of  movement.  The  stage  of  supervision  ought  to 
be  continued  for  at  least  three  months  in  even  the  most  favourable  case. 
The  brace  is  then  removed  at  intervals  and  finally  discarded  entirely.  When 
the  brace  has  been  discarded  the  patient  should  be  trained  to  walk  with 
equal  steps,  placing  each  limb  as  far  as  possible  upon  an  equality  with  its 
fellow,  and  adapting  the  stronger  to  the  weaker  member.  This  precaution 
has  an  important  iiilluence  in  checking  the  tendency  to  deformity,  and  in 


Fio.  116.— The 
coQvalesceathip 
splint. 


modifying  or  even  concealing  any  limp 


which  mav  exist. 


236  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

(5)  Treatment  of  Deformities 

The  deformities  which  may  occur  in  the  course  of  the  disease  are  those 
of  flexion,  abduction,  adduction,  or  a  combination  of  either  of  the  two  last 
mentioned  with  flexion.  The  deformities  of  eversion  and  inversion  may  be 
neglected,  as  they  are  so  dependent  upon  the  position  of  abduction  or 
adduction.  According  as  they  occur  in  the  early  or  in  the  later  stages  of 
the  disease  the  deformities  have  various  origins.  Early  they  are  the  result 
of  muscular  spasm,  later  they  depend  upon  contraction  of  the  soft  parts 
and  alteration  in  the  bony  outlines.  The  treatment  may  be  considered 
under  the  headings  of 

(A)  Gradual  correction. 

(B)  Rapid  correction. 

(C)  Operative  correction. 

(A)  Gradual  Correction 

There  are  four  methods  of  gradual  correction  which  fall  to  be  discussed  : 

By  weight  and  pulley. 

By  the  traction  splint. 

By  the  plaster  bandage. 

By  the  Thomas  splint. 
By  Weight  and  Pulley. — Some  directions  have  been  given  in  the  applica^ 
tion  of  these  (page  102).  After  the  extension  plasters  are  appHed  to  the 
limb  the  latter  is  placed  in  such  a  position  that  the  iliac  spines  are  on  the 
same  level  and  the  lumbar  spine  rests  upon  the  mattress.  The  fulfilment 
of  these  obligations  will  maintain  the  limb  in  a  deformed  position,  and  at 
first  the  extension  is  to  be  applied  in  such  an  axis.^  The  limb  may  be  sup- 
ported upon  a  pillow  or  upon  an  adjustable  wooden  triangle,  the  extension 
bemu  applied  over  a  pulley  in  the  line  of  the  elevated  leg.  As  in  Buck's  system 
of  extension,  the  foot  of  the  bed  may  be  raised  in  order  to  increase  the  friction 
of  the  body  and  so  to  counteract  the  traction.  In  young  children  this  pro- 
cedure may  be  insufficient,  and  a  direct  counter -extension  may  become 
necessary.  This  is  best  secured  by  a  couple  of  perineal  bands  which  pass 
upon  each  side,  above  and  below  the  patient,  and  are  attached  to  the  top 
corners  of  the  bed.  In  order  to  secure  efficient  traction  the  patient  must 
not  be  allowed  to  sit  up,  therefore  a  swathe  is  applied  around  the  body  and 
fastened  to  the  bed,  or  shoulder  straps  are  applied.  If  it  is  necessary  to  fix 
the  patient  more  completely,  it  is  well  to  use  a  long  lateral  splint  extending 
from  the  axilla  to  beyond  the  foot  and  attached  below  to  a  cross  bar.  The 
bed-clothes  are  held  from  the  raised  limb  by  some  variety  of  cradle.  At 
first  the  traction  weight  must  not  be  great,  but  from  day  to  day  it  is  increased. 
After  traction  has  been  maintained  for  two  or  three  days  in  the  deformed 
position  the  axis  of  the  limb  is  gradually  altered  until  it  more  exactly 
approximates  to  the  normal.     The  flexion  is  reduced  and  the   adduction 

'  This  detail  was  first  pointed  out  by  Professor  Howard  Marsh. 


HIP-JOINT  DISEASE  237 

or  abduction  gradually  corrected.  The  process  of  correction  is  slow,  as  it 
depends  upon  a  stretching  of  the  shortened  soft  tissue  structures  ;  the 
method  is  valueless  when  there  is  osseous  ankylosis  or  bone  deformity. 

By  the  Traction  Splint. — The  application  of  this  splint  has  been  dis- 
cussed, and  it  has  a  distinct  place  in  the  treatment  of  the  correction  of 
deformity.  The  principle  of  its  action  is  similar  to  that  of  the  weight  and 
pulley  in  which  the  shrunken  soft  structures  are  gradually  stretched.  It 
possesses  the  advantage  that  its  action  can  be  maintained  and  yet  the 
patient  is  able  to  go  aboiit,  crutches  and  a  high  patten  on  the  opposite  foot 
being  used.  There  is,  however,  the  great  disadvantage  that  it  is  difficult 
to  so  alter  the  long  axis  of  the  splint  that  it  fits  the  deformed  hmb.  It  is, 
therefore,  often  impossible  to  secure  traction  in  the  proper  direction. 

By  the  Plaster  Bandage. — When  this  method  is  adopted  the  original 
plaster  bandage  is  applied  to  the  limb  in  its  deformed  position.  It  is  kept 
in  position  for  four  weeks,  and  during  that  time  the  rest  and  fixation  have 
done  much  to  relieve  the  muscular  spasm  which  may  be  playing  a  very 
considerable  part  in  the  deformity.  Therefore,  when  the  first  case  is  re- 
moved the  deformity  may  be  very  considerably  reduced.  If  some  degree 
of  malposition  still  exists  an  accurately  fitting  second  case  is  applied,  and 
when  it  is  removed  at  the  end  of  the  second  month  it  may  be  found  that  the 
deformity  can  be  completely  reduced. 

By  Thomas  Splint. —  In  children  a  satisfactory  correction  is  obtained 
by  using  the  double  Thomas  splint.  The  sound  limb  is  fixed  in  the  extended 
position,  while  the  displaced  limb  is  supported  by  the  other  arm  of  the 
splint,  straight  or  bent  to  the  angle  of  the  deformity.  The  splint  is  best 
suited  for  the  correction  of  a  flexion  deformity.  The  common  mistake  has 
already  been  alluded  to  of  shaping  a  Thomas  splint  above  the  buttock  to 
fit  the  lumbar  lordosis.  A  correctly  made  splint,  in  which  the  portions  of 
the  upright  above  and  below  the  pelvis  are  straight  and  in  parallel  planes, 
exercises  a  continuous  corrective  action  on  a  flexion  deformity.  A  splint 
altered,  as  has  been  described,  is  useless  as  a  corrective  agent.  When  the 
flexion  deformity  is  too  great  to  be  treated  by  the  straight  splint,  the  arm  of 
the  splint  supporting  the  diseased  limb  is  bent  by  wrenches  to  such  a  position 
that  it  fits  the  deformity.  As  the  muscular  spasm  subsides  the  splint  is 
straightened  slightly  from  time  to  time  at  a  point  opposite  the  hip-joint, 
so  as  to  conform  to  the  improved  position.  This  is  done  until  the  limb  is 
straightened.  If  there  is  much  flexion  it  is  advisable  to  reduce  it  as  far  as 
possible  by  weight  extension  before  applying  a  corrective  Thomas  splint. 

The  deformities  of  abduction  and  adduction  are  much  more  difficult 
to  correct  than  that  of  flexion.  If  there  exists  any  degree  of  abduction  a 
wing  should  be  attached  to  the  splint  which  passes  round  the  flank  on  the 
side  0])])()site  to  the  disease.  The  wing  is  made  from  the  same-sized  iron 
as  the  thigh  band  of  the  splint.  It  is  placed  at  such  a  point  that  it  will 
pass  round  the  flank  midway  between  the  rib  border  and  tlie  crest  of  the 
ilium  ;  this  point  is  usually  situated  upon  the  vertical  of  the  splint  midway 
between  the  chest  band  and  the  buttock  bend.     Assuming  that  the  right 


238  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

leg  is  the  one  afiected  :  to  counteract  abduction  the  band  is  fitted  to  the  right 
side  of  the  body,  to  counteract  adduction  the  band  is  fitted  to  the  left  side. 
The  splint  is  applied  so  that  the  correcting  band  exerts  considerable  pressure ; 
from  time  to  time  this  pressure  is  increased  by  altering  the  curve  of  the  band. 
These  bands  are  slow  and  uncertain  methods  of  correction.  One  would 
prefer  to  speak  of  them  as  safeguards  against,  rather  than  active  correctives 
of  the  deformity. 

(B)  Rapid  Correction 

It  must  be  remembered  that  this  method  is  absolutely  contra- 
indicated  in  the  acute  stages  of  the  disease.  It  is  found  suitable  in 
cases  in  which  the  disease  has  subsided,  in  which  the  deformity  does 
not  yield  to  recumbency  and  traction,  and  in  which  the  deformity 
depends  upon  a  shortening  of  the  soft  parts.  The  reduction  may  be  carried 
out  at  one  attempt  or  by  repeated  sittings.  It  consists  in  a  manual  or 
mechanical  stretching  of  the  shortened  parts  and  the  reduction  of  the 
deformity,  the  patient  being  deeply  under  the  influence  of  an  anaesthetic. 
To  ensure  a  complete  reduction  it  may  be  necessary  to  divide  shortened 
flexor  or  adductor  muscles.  After  the  correction,  or  after  each  correction, 
the  limb  is  fixed  in  a  splint  of  plaster  of  Paris.  The  treatment  possesses  the 
advantage  of  rapidity.  Its  disadvantages  are  the  tendencies  which  it  ias 
of  being  followed  by  tuberculous  meningitis,  fresh  local  tuberculosis,  or 
abscess  formation. 

(C)  Operative  Correction 

When  the  deformity  is  associated  with  a  bony  ankylosis  in  the 
deformed  position,  operative  treatment  in  the  shape  of  an  osteotomy  is  the 
only  procedure  which  should  be  carried  out.  Dift'erent  osteotomies  have 
been  done  under  the  names  of  Adams's  operation,  inter  -  trochanteric 
osteotomy,  Barton's  operation,  snb-trochanteric  osteotomy,  and  Jones's 
operation  for  correction  of  adduction  and  shortening. 

Adams's  Operation. — The  patient  being  placed  on  the  opposite  side,  a 
long,  narrow-bladed  knife  is  introduced  a  finger-breadth  above  the  top 
of  the  trochanter  major,  and  pushed  onwards  until  it  encounters  the  neck 
of  the  femur.  The  knife  is  passed  over  the  neck  of  the  femur  in  a  direction 
at  right  angles  to  the  axis  of  the  neck.  The  route  taken  by  the  knife  is 
practically  one  parallel  to  Poupart's  ligament.  The  knife  is  left  in  situ 
and  an  Adams's  or  a  Jones's  saw  is  passed  alongside  the  knife  until  the  teeth 
of  the  saw  are  in  contact  with  the  femoral  neck ;  the  knife  is  then  removed. 
The  neck  of  the  bone  is  divided  within  the  capsule  of  the  joint.  While 
sawing,  one  is  liable  to  pull  Adams's  saw  out  of  the  cut  in  the  bone  and  have 
much  difficulty  in  reintroducing  it.  The  hook  or  the  beak  upon  a  Jones's 
saw  prevents  such  an  accident.  The  bone  may  be  entu-ely  divided,  or  the 
division  may  be  incomplete  and  the  deformity  completely  corrected  by  break- 
ing across  the  remainder  of  the  neck  of  the  bone.  Before  obtaining  complete 
rectification  it  may  be  necessary  to  divide  the  tendons  of  the  adductor 


HIP-JOINT  DISEASE  239 

longus,  sartorius,  and  perhaps  the  rectus  muscles.  After  rectification  the 
Hmb  is  immobilised  in  a  position  of  slight  flexion  and  abduction. 

The  operation  has  two  advantages  to  recommend  it :  (1)  the  amount  of 
shortening  which  accompanies  it  is  less  than  occurs  in  the  other  corrective 
operations  ;  (2)  the  fragments  unite  without  any  marked  degree  of  displace- 
ment. As  there  are  advantages  so  there  are  distinct  disadvantages.  The 
operation  being  subcutaneous  it  is  exceedingly  difficult  to  be  sure  where  the 
section  is  being  made,  more  especially  as  the  contour  of  the  neck  may  be 
altered  by  disease.  Another  point  is  that  often  the  bone  is  so  intensely  hard 
that  a  most  inordinate  time  may  be  necessary  to  secure  its  division. 

To  overcome  the  disadvantages  of  a  subcutaneous  operation  the  division 
is  sometimes  made  through  a  small  open  incision.  At  a  point  immediately 
above  the  great  trochanter  a  vertical  incision,  1  inch  long,  is  made  down  to 
the  neck  of  the  femur.  An  osteotome  is  introduced  alongside  the  knife,  and 
the  latter  withdrawn.  The  edge  of  the  osteotome  is  turned  transversely 
to  the  neck  of  the  femur  and  the  bone  completely  divided. 

The  two  above-mentioned  operations,  the  common  feature  of  which  is 
division  of  the  femoral  neck,  are  suitable  in  cases  of  bony  ankylosis  when 
flexion  is  the  deformity  present. 

Inler-trochanteric  Osteotomy.  Sayre's  Operation. — A  vertical  incision 
is  made  from  a  point  just  above  the  tip  of  the  great  trochanter  downwards 
for  6  inches  along  the  mid  line  of  the  outer  surface  of  the  femur.  From  the 
centre  of  this  incision  a  transverse  cut  is  made  directly  backwards  for  a 
short  distance.  The  outer,  anterior,  and  posterior  surfaces  of  the  upper  end 
of  the  femur  are  exposed  by  means  of  a  periosteal  elevator  until  the  trochanter 
minor  can  be  felt.  A  Gigli  saw  is  passed  around  the  femur  between  the 
major  and  minor  trochanters  and  the  bone  divided.  Sayre  removed  a 
triangular  portion  of  bone,  and  rounded  the  upper  end  of  the  lower  fragment 
in  such  a  way  that  it  fitted  into  a  depression  upon  the  under  surface  of  the 
upper  fragment.  He  hoped,  by  so  doing,  to  secure  a  movable  joint,  but  this 
hope  is  without  much  foundation. 

The  operation  has  the  disadvantages  that  it  is  difficult  to  perform,  and, 
further,  that  as  the  division  of  the  bone  is  carried  out  above  the  insertion  of 
the  psoas  there  is  a  tendency  to  tilting  of  the  lower  fragment  and  the  forma- 
tion of  an  unsightly  mass  of  callus  in  the  centre  of  the  groin. 

Barton's  Operation.  Trochanteric  Osteotomy. — Barton  of  Philadelphia 
was  the  first  to  correct  the  deformity  of  hip  ankylosis  by  osteotomv,  and  the 
line  of  section  which  he  recommended  was  through  the  trochanter  major. 
The  operation  is  not  now  performed.  Trochanteric  and  inter-trochanteric 
osteotomy  resemble  cervical  osteotomy  in  so  far  as  thev  are  indicated  in 
cases  of  deformity  duo  to  flexion  ;  they  are  not  suitable  as  corrective  measures 
of  adduction  and  abduction. 

SiibtrocIifiHleric  Osteotomy.  -Under  this  heading  three  distinct  types  of 
osteotomy  have  been  described.  They  possess  certain  common  advantages  : 
(1)  The  operations  are  easy  in  performance.  (2)  The  operation  field  is  remote 
from  the  joint,  a  point  of  considerable  importance  in  dealing  with  a  tuber- 


240  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

culous  ankylosis.  (3)  As  the  section  is  made  below  the  insertion  of  the 
psoas  muscle,  there  is  less  tendency  to  recurrence  of  the  deformity  by  the 
j)ull  of  the  muscle. 

Transverse  Linear  Subtrochanteric  Osteotomy.  Gant's  Operation. — At  a 
point  2  inches  below  the  tip  of  the  great  trochanter,  an  incision  is  made 
downwards  over  the  outer  surface  of  the  femur  down  to  the  bone.  An 
osteotome  is  introduced  into  the  incision,  its  cutting  edge  being  parallel  to 
the  long  axis  of  the  wound.  When  the  bone  is  reached  the  cutting  edge  is 
turned  so  that  it  becomes  transverse.  The  bone  is  divided  with  the  osteotome 
and  the  limb  immobilised  in  a  good  position. 

Oblique  Litiear  Subtrochanteric  Osteotomy  (Terrier-Hannequin). — In  its 
preliminary  steps  the  operation  resembles  Gant's.  The  bone  is  divided  with 
an  osteotome  or  chisel,  and  the  section  is  made  obliquely  from  above  down- 
wards and  inwards.  The  antero-posterior  plane  of  section  ought  to  be 
slightly  oblique  from  in  front  backwards  and  inwards.  By  this  manoeuvre 
a  subsequent  better  apposition  of  fragments  is  obtained,  and  if  weight  ex- 
tension is  applied  the  obliquely  divided  surfaces  may  be  induced  to  slide 
upon  one  another  and  so  jiroduce  some  degree  of  lengthening. 

Cuneiform  Subtrochanteric  Osteotomy. — A  3-inch  vertical  incision  is  made 
over  the  external  surface  of  the  femur,  the  centre  of  the  incision  being  situated 
about  2  inches  below  the  tip  of  the  great  trochanter.  The  outer  surface  of 
the  bone  having  been  exposed,  a  wedge  of  bone  is  removed  with  chisel  and 
mallet.  The  wedge  removed  is  so  placed  that  its  removal  corrects  the 
deformity,  whatever  it  may  be,  e.g.  in  a  flexion  deformity  the  base  of  the 
wedge  will  lie  posteriorly,  in  an  adduction  deformity  it  will  lie  external. 
After  removal  of  the  wedge  the  bone  is  straightened,  and  the  part  dressed 
and  immobilised  in  a  proper  position  of  slight  abduction  and  flexion. 

Jones's  Operation  to  correct  Adduction  Deformity  with  Shortening. — 
Jones  overcomes  the  deformity  of  adduction  and  real  shortening  by  an 
osteotomy  and  extension  of  the  leg.  A  trans-trochanteric  osteotomy  is  done. 
By  keeping  the  femur  in  abduction  with  the  pelvis,  the  elevation  of  the 
pelvis  on  the  opposite  side  is  affected.  With  an  outstretched  thigh  in  one 
piece  with  the  trunk  it  is  clear  that  the  limb  can  only  be  adducted  at  the 
cost  of  elevating  the  pelvis  on  the  sound  side,  and  in  this  way  several  inches 
of  shortening  may  be  remedied. 

(6)  Treatment  of  Complications 

Abscess  Formation. — A  considerable  proportion  of  cases  of  hip-joint 
disease  pass  on  to  abscess  formation,  and  it  may  be  looked  upon  as  an 
indication  of  an  extension  of  the  disease.  Abscesses  are  more  likely  to 
occur  in  cases  which  are  being  treated  with  improper  and  incomplete 
fixation,  and  their  formation  ought  at  once  to  call  in  question  the  methods 
of  immobilisation  which  are  being  employed. 

Conservative  Treatment. — In  considering  this  treatment  it  must  first  be 
borne  in  mind  that  a  small  yet  a  certain  proportion  of  hip  abscesses  become 


HIP-JOINT  DISEASE  241 

shut  ofi  and  ultimately  entirely  absorbed,  if,  and  this  is  the  important  detail, 
the  most  scrupulous  care  is  taken  to  ensure  absolute  fixation  of  the  diseased 
joint.  It  is  well,  therefore,  to  delay  any  very  active  line  of  treatment  until 
nature  has  been  put  at  the  very  best  advantage  for  a  spontaneous  cure. 

Aspiration  and  Injection. — But  in  a  very  large  proportion  of  cases  such 
passive  methods  are  unsuccessful.  The  abscess  continues  to  increase  in  size 
and  to  track  to  other  situations,  and  pain  becomes  more  persistent  and 
severe.  One's  choice  of  treatment  now  lies  between  that  of  aspiration  with 
or  without  injection  of  medicaments,  and  incision  with  evacuation  of  the  pus. 
It  is  stated  that  aspiration  with  or  without  injection  has  given  excellent 
results.  The  abscess  is  aspirated  when  it  becomes  superficial.  The  technique 
of  aspiration  has  been  discussed  upon  page  77,  et  seq.,  and  situations  in 
which  hip  abscesses  most  commonly  appear  are  detailed  upon  page  217. 
It  occasionally  happens  that  the  abscess  remains  localised  by  the  capsular 
ligament,  and  as  the  fluid  is  sometimes  retained  here  under  considerable 
tension,  an  abscess  in  this  situation  is  one  of  the  most  painful  with  which 
one  has  to  deal.  There  being  little  or  no  superficial  bulging,  the  joint  is 
entered  by  certain  definite  anatomical  landmarks.  The  needle  ought  to  be 
about  31-  inches  long.  The  patient  lies  on  his  back  in  such  a  position  that 
the  leg  is  adducted  and  rotated  slightly  inwards.  The  needle  is  introduced 
at  right  angles  to  the  axis  of  the  femur  at  a  point  immediately  above  the  tip 
of  the  great  trochanter  and  midway  between  its  anterior  and  posterior 
borders.  The  needle  being  pushed  slowly  inwards  its  point  comes  into 
contact  with  the  head  or  neck  of  the  femur.  The  limb  is  then  strongly 
adducted,  and  the  needle  point  being  kept  in  contact  with  bone,  is  piished 
over  the  head  into  the  joint.  The  needle  enters  the  joint  between  the  head 
of  the  femur  and  the  rim  of  the  acetabulum. 

Incision. — There  are  conditions  under  which  aspiration  of  the  abscess 
becomes  impossible  or  undesirable,  and  one  has  to  fall  back  upon  free  incision. 
The  contents  of  the  abscess  may  be  so  thick  and  inspissated  that  their  aspua- 
tion  is  impossible.  The  presence  of  a  sequestrum  Ij'ing  in  the  confines  of  the 
abscess  cavity  is  an  indication  for  free  incision.  An  abscess  which  has 
become  involved  with  a  secondary  infection  siumld  only  be  dealt  with  by 
free  incision.  These  are  the  commoner  indications.  As  an  operation  the 
evacuation  of  a  tuberculous  abscess  calls  for  the  most  rigid  asepsis.  The 
cavity  is  freely  opened  and  emptied,  and  any  loose  bone  or  sequestra  are 
removed.  It  has  been  said  that  it  is  unwise  to  remove  the  pyogenic  mem- 
brane lining  the  abscess  wall,  as  it  acts  as  a  barrier  preventing  infection  of 
the  soft  tissues  around.  As  the  wall  of  a  cold  abscess  is  lined  by  actively 
developing  tubercles,  this  advice  is  one  of  doubtful  value.  It  is  probably 
best  to  use  a  pledget  of  gauze  in  such  a  way  that  it  removes  the  pyogenic 
membrane  without  seriously  damaging  the  surrounding  soft  tissues.  The 
interior  of  the  abscess  may  be  washed  out  with  a  stream  of  hot  sterile  saline, 
and  wIkmi  the  cavity  is  thoroughly  dried  the  walls  are  rubbed  with  a  quantity 
of  bismutii  and  iodoform  paste.  Then,  the  question  arises  whether  the 
wound  is  to  be  drained  or  immediately  closed.     It  is  advisable  to  close  the 

16 


242  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

woimd  completely,  and  if  the  operation  has  been  carried  out  with  proper 
regard  to  asepsis  the  parts  heal  by  first  intention.  Drainage  acts  as  an 
invitation  to  sepsis.  A  pad  and  firm  bandage  applied  over  the  situation 
of  the  abscess  tends  to  prevent  the  re-accumulation  of  fluid. 

Sinus  Formation. — The  prevention  of  sinus  formation  ought  to  be 
one  of  the  aims  of  one's  treatment,  for  the  occurrence  of  a  sinus  constitutes 
a  serious  complication.  When  the  sinuses  have  formed  it  is  not  advisable 
to  at  once  proceed  to  active  methods  of  treatment.  An  opportunity  must 
be  given  for  the  development  of  a  salutary  fibrosis  by  which  alone  a  cure 
can  be  effected.  A  sinus  from  which  the  flow  of  pus  is  diminishing,  the 
general  health  being  maintained,  ought  to  be  left  alone.  The  persistence 
and  increase  of  the  sinus  discharge  may  be  indicative  of  an  extension  of  the 
bone  caries  or  of  the  formation  of  a  sequestrum.  The  possibilities  are  proved 
or  disproved  by  X-ray  examination,  and  the  presence  of  either  may  call  for 
an  opening  up  of  the  sinus  and  radical  treatment  of  the  bone.  The 
various  methods  of  dealing  with  sinuses  have  been  discussed. 

(7)  Operative  Treatment  of  Hip-Joint  Disease 

Endless  discussion  has  been  waged  around  the  question  of  when 
operative  treatment,  excision  or  erasion,  should  be  employed  in  the  treat- 
ment of  tuberculous  joints.  There  are  authorities  who  say  that  operative 
measures,  as  far  as  excision  is  concerned,  are  at  all  times  unjustifiable.- 
Bowlby,^  for  example,  has  given  an  interesting  account  of  his  experiences 
for  the  past  twenty-one  years  at  the  Alexandra  Hip  Hospital.  Nine  hundred 
cases  have  been  treated  without  a  single  case  of  excision,  and  of  these, 
many  of  them  taken  from  the  poorer  classes  and  many  of  them  with 
advanced  disease,  a  percentage  of  96  recovered.  There  are  surgeons  who 
take  a  view  almost  the  exact  opposite  of  this,  and  recommend  excision  in  a 
very  large  proportion  of  their  cases.  Lastly,  there  are  men  who  give  con- 
servative measures  every  chance,  but  when  these  are  unsuccessful  and  the 
indications  are  propitious  do  not  hesitate  to  carry  out  a  thorough  excision. 
Something  is  to  be  said  for  each  of  these  attitudes.  The  thorough  con- 
servatist  claims  certain  advantages  for  his  procedure.  The  deleterious  effects 
of  operation  are  avoided,  there  is  a  minimum  of  risk  of  dissemination  of  the 
disease,  and  there  is  a  possibility  that  cure  may  be  obtained  with  a  good 
functional  limb.  There  is  no  disguising  the  fact  that  conservation 
possesses  distinct  disadvantages.  Of  these  the  most  obtrusive  is  the 
duration  of  time  required  in  treatment ;  three  to  fom-  years  are  probably 
necessary,  and,  while,  in  the  well-to-do  classes  this  may  be  a  mere  bagatelle, 
among  the  poorer  classes  it  may  constitute  an  obstacle  which  there  is  no 
getting  past.  In  Scotland,  at  least,  there  are  very  few  institutions  in 
which  prolonged  residence  for  poor  children  is  possible.  The  second  dis- 
advantage of  thorough  conservatism  is  the  risk  that  in  spite  of  every 
precaution  the  disease  continues  to  extend. 

'  Bowlby,  A.  A.,  Brit.  Med.  Joiirn.,  1908,  i.  U65. 


HIP-JOINT  DISEASE  243 

There  are  few  who  advocate  the  line  of  treatment  of  immediate 
operation.  The  advantages  they  claim  are  the  minimising  of  time  and  the 
possibility  of  getting  rid  at  once  of  all  the  disease.  But  over  against  these 
benefits  one  must  set  the  fact  that  they  are  often  bought  at  the  expense 
of  an  ankylosed  hip  with  a  varying  degree  of  shortening  and  deformity. 

The  third  line  of  consideration  has  much  to  recommend  it.  Con- 
servative measures  are  thoroughly  carried  out,  and  if  a  cure  results  so 
much  the  better.  There  is  no  hesitation  in  recommending  excision  or 
erasion  if  either  are  indicated.  One's  experience  has  been  that  the  last  is 
the  most  rational  attitude  to  adopt  towards  this  question  of  operation. 
There  is  no  element  of  dogmatism  about  it,  the  treatment  is  suited  to 
the  demands  of  the  disease,  and  nature  herself  is  given  every  chance  to 
effect  a  cure.  There  are  cases  which  illustrate  to  a  marked  degree  the 
value  of  operation.  A  child  who,  before  operation,  has  been  tortured  with 
pain  and  divitalised  by  toxsemia  and  suppuration  steadily  improves  after 
excision  is  performed.  Excision  of  the  hip-joint  has  hitherto  been  associated 
with  the  idea  that  the  operation  is  necessarily  followed  by  a  flaU  limb,  this  is 
an  entirely  unfounded  belief  ;  proper  observance  of  operative  technique  will 
guarantee  an  ankylosed  joint,  which  for  practical  purposes  is  often  a 
useful  one. 

Indications  for  Operation. — ^Vhat  may  one  consider  as  indications 
for  operative  treatment  ?  They  may  be  summarised  as  follows  :  (1)  The 
occurrence  of  abscess  formation  with  a  steady  progression  of  the  disease. 
(2)  A  persistent  loss  of  health.  (3)  The  uncontrollable  occurrence  of  pain. 
(4)  Imperfect  home  conditions,  under  which  efficient  conservative  treatment 
is  impossible.  In  a  doubtful  case  invaluable  information  may  be  obtained 
by  examining  the  joint  while  the  patient  is  under  an  anaesthetic.  The  grating 
sensation  of  approximated  diseased  bone  surfaces  can  be  appreciated  by 
this  means. 

Operative  Possibilities.  —  The  operative  possibilities  consist  in 
complete  excision  of  the  hip-joint  or  in  local  curetting. 

Methods  of  Excision. — In  performing  the  operation  of  excision  one 
keeps  two  ideals  in  view.  These  ideals  are  the  removal  as  far  as  possible 
of  the  diseased  tissue,  and  the  possession  after  operation  of  a  limb  which 
is  stable  and  useful.  In  planning  the  incision  to  be  adopted  these  two 
necessities  ought  to  be  kept  before  one,  but  owing  to  the  peculiar  anatomy 
of  the  joint  they  are  somewhat  difficult  to  fulfil.  The  joint  may  be  exposed 
by  throe  possible  routes — anterior,  external,  and  posterior. 

Anterior  Excision. — Several  methods  have  been  devised  for  excising 
tlie  joint  through  an  anterior  incision.  The  best  known  is  that  of  Parker, 
it  has  been  strongly  recommended  by  A.  E.  Barker  and  by  Hueter. 

Preliminaries. — The  usual  preparations  for  an;T3stlietic  are  followed. 
In  the  preparation  of  the  limb  before  operation  the  ])urification  siiould 
include  tlio  whole  lower  limb  with  the  pelvis.  At  operation  the  limb  of 
the  diseased  hip  is  encased  in  a  sterile  towel  fastened  with  a  sterile  bandage  ; 
the  part  is  thus  free  to  be  moved  about  in  any  desired  direction. 

IGa 


244 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


Operation. — The  patient  lying  on  his  back,  an  incision  3  to  4  inches  long 
is  made  downwards  and  slightly  inwards  from  a  point  h  an  inch  below  and 

external  to  the  anterior  superior 
spine  of  the  ilium.  The  upper 
part  of  the  incision  runs  along  the 
outer  border  of  the  sartorius 
muscle,  the  lower  half  of  the  in- 
cision is  midwaj^  between  the 
sartorius  and  the  tensor  fasciae 
femoris.  The  incision  is  deepened, 
and  the  sartorius  and  rectus  femoris 
muscles  are  retracted  inwards. 
The  joint  capsule  is  now  exposed. 
The  capsule  is  opened  by  an  in- 
cision parallel  to  the  neck  of  the 
femur. 

It  is  not  advisable  to  attempt 
to  dislocate  the  head  of  the  femur 
through  the  incision,  in  all  proba- 
bility any  such  attempt  would 
fail.  Instead,  the  neck  of  the 
femxir  is  divided  in  situ  with  an 
osteotome  or  saw,  and  the  femoral 
head  removed.  Even  at  this  stage 
difficulty  may  be  experienced  in  removing  the  head  of  the  bone,  but 
as  it  is  usually  rarefied  and  softened  bv  tuberculous  disease  it  is  easily 


Fig.  117. — Incision  for  anterior  exci.sion  of  the 
hip-joiut. 


TF.F 


Fi«.  118. — E.^cision  of  tlie  hip  by  the  anterior  route.     Steps  in  the  dissection. 

.?.  =  Sartorius.  T.F.T.  =  Tensor  fasciae  femoris. 

K.F.=Rectus  femoris.  r.jE.-Vastus  externus. 

(?..!/.  =  Gluteus  medius. 


extracted.  With  curette,  forceps,  and  curved  scissors  as  much  diseased 
tissue  as  possible  is  removed.  The  acetabulum  is  examined  and  any 
apparent  disease  is  removed.  When  one  is  satisfied  that  the  eradication 
of  disease  is  as  thorough  as  possible,  the  divided  neck  of  the  bone  is  rounded 


HIP-JOINT  DISEASE 


245 


and  trimmed,  and  by  abducting  the  limb  it  is  jammed  against  the  floor  of 
the  acetabulum.  It  is  maintained  in  this  position  for  reasons  to  be  presently 
mentioned.  The  remains  of  the  capsule  are  united  with  catgut,  the  muscles 
are  brought  back  into  position  and  stitched,  and  the  skin  wound  closed. 
If  there  is  no  secondary  infection  the  wound  is  closed  without  dramage. 
If  sinuses  are  present  it  will  be  necessary  to  provide  for  drainage,  and  this 
is  most  satisfactorily  estabhshed  by  a  stab  wound  passing  to  the  back 
through  the  buttock. 

After-treatment. — As  tliis  is  similar  in  the  different  methods  of  excision 
it  will  be  discussed  later  under  a  common  heading.  The  anterior  route  has 
the  advantage  of  not  necessitating  the  division  of  any  muscles,  and  in  the 
post  operative  treatment  the  situation  of  the  incision  is  such  that  the  wound 
is  easily  dressed.  These  advantages  are  more  than  counterbalanced  by  the 
insufficiency  of  space  which  the  incision  affords,  for  while  it  gives  good  access 
to  the  upper  end  of  the  femur  it  does  not  sufficiently  expose  the  acetabulum. 
The  incision  is  useful  in  dealing  with  foci  in  the  head  and  neck  of  the  femur, 
but  these  of  course  are  best  treated  by  conservative  means. 

External    Excision. — Langenbeck's   name  is   associated   vnth    this 
incision,  and  the  details  of  the  operation  have  been  systematised  by  Konig. 
The  preliminaries  are  similar  to  those  already  de- 
scribed, and  the  patient  is  placed  on  his  sovmd  side. 

Operation. — An  incision  about  5  inches  long  is 
made  in  the  axis  of  the  limb  over  the  centre  of  the 
trochanter  ;  half  of  the  incision  lies  above  the  level 
of  the  trochanter.  The  incision  exposes  the  gluteus 
maximus  above,  the  vastus  externus  below,  and  the 
area  of  aponeurosis  which  lies  over  the  outer  surface 
of  the  trochanter.  The  gluteus  maximus  is  split 
and  retracted,  and  the  gluteus  mediiis  is  exposed  as 
it  passes  to  its  insertion  along  the  oblique  line  upon 
the  outer  surface  of  the  trochanter.  The  gluteus 
medius  is  pulled  forwards  to  expose  the  pyriformis 
behijid  and  the  gluteus  minimus  in  front.  The 
interval    between    these    two    muscles   is   opened  ^""'•. "°- "7 \°"^',''."  (J"^  f,*^' 

i    .  cision   of  the  hip  by   thi.- 

up   and  the  capsular  ligament  exposed.     The  liga-       e.\tcrnal  route. 
ment  is  divided  over  the  head  and  neck  of  the  femur 

in  the  line  of  the  original  incision,  and  in  the  same  direction  the  periosteum 
is  split  over  the  outer  surface  of  the  trochanter.  With  a  broad  chisel  shells 
of  cartilage  are  detached  from  the  anterior  and  posterior  surfaces  of  the 
trochanter  in  such  a  way  that  they  open  outwards  as  upon  hinges.  The 
separated  shells  of  bone  carry  the  insertions  of  the  trochanteric  muscles. 
With  a  periosteal  elevator  the  neck  of  the  bone  is  now  bared  and  the  bone 
divided  with  finger  saw,  Gigli  saw,  or  broad  chisel.  The  femoral  head  is 
removed  ;  there  is  difficulty  in  doing  so,  but  some  additional  room  may  be 
gained  by  pulling  on  the  limb.  In  unu.sually  difficult  cases  it  may  be 
necessary  to  ciiisel    away  the  posterior  superior  rim   of   the  acetabulum. 


246 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


The  diseased  synovial  tissues  are  removed  with  sharp  spoon  and  scissors. 
The  floor  of  the  acetabulum  is  examined  for  disease  and  any  suspicious  bone 
is  chiselled  away.  An  important  pocket  of  synovial  membrane  should  be 
curetted  as  it  runs  downwards  towards  the  lesser  trochanter.  Before  closing 
the  wound  the  upper  end  of  the  femur  is  rounded  so  that  it  may  fit  the  con- 
cave acetabulum  when  it  is  placed  in  contact  with  it.  The  interior  of  the 
cavity  is  rubbed  with  iodoform  and  bismuth  paste.  The  flaps  detached 
from  the  trochanter  and  the  various  muscles  are  brought  back  and  sutured 


Fig.  120. — Excision  of  the  hip  by  the  e.xternal  route.     Steps  in  the  dissection. 


G.M.  ^Gluteus  luaxiinus. 
G.M^.  =  Ghiteus  medius. 

P.  —  Pyriforinis. 


F.£.  =  Vastus  externus. 
C?.il/^v.  =  Gluteus  minimus. 


in  position  with  interrupted  catgut  stitches  and  the  skin  wound  closed.  In 
the  absence  of  a  secondary  infection  it  is  unnecessary  to  provide  drainage. 

This  method  gives  good  access  to  the  joint,  and  it  is  more  particularly 
adapted  to  cases  in  which  it  is  necessary  to  remove  the  trochanter  as  well 
as  the  head  and  neck  of  the  bone. 

Posterior  Excision.  Kocher's. — This  route  has  been  recommended 
because  it  undoubtedly  jjrovides  the  best  access  to  both  the  femoral  head 
and  the  acetabulum.  It  has  the  fiuther  advantage  of  being  as  suitable  for 
arthrotomy  as  for  arthrectomy. 

Operation. — The  patient  is  placed  in  the  semi-lateral  position  with 
the  thigh,  which  is  underneath,  exteiided,  and  that  which  is  above  flexed 


HIP-JOINT  DISEASE 


247 


and  adducted.     The  incision  begins  some  little  distance  below  and  to  the 
outer  side  of  the  posterior  superior  spine  of  the  ilium.     It  extends  down- 
wards to  the  posterior  superior  angle  of  the  trochanter  and  along  the  long 
axis  of  the  femur  to  a  short  distance  below  the  trochanter.     The  fleshy 
portion  of  the  gluteus  maximus  is  split  in  the  long  axis  of  its  fibres,  and 
the  aponeurotic  part  divided  to  expose  the  tendon  of  the  vastus  externus. 
Retraction  of  the  edges  of  the  wound  exposes  the  insertion  of  the  gluteus 
medius  into  the  oblique  line  upon  the  trochanter,  with  a  quantity  of  fatty 
tissue  above  and  the  tendon  of  the  vastus  externus  below.     The  gluteus 
medius  is  detached  from  the  great  trochanter  by  an  incision  which  runs 
parallel  to  its  insertion  from  the  posterior  superior  to  the  anterior  inferior 
angle.     The  tendon  is  separated  by  including 
with  it  a  scale  of  cartUage,  and  a  knife  is 
used  in  the  procedure.     The  lower  border  of 
the    separated    gluteus    medius  is  retracted 
upwards  until  the  upper  and  anterior  borders 
of  the  trochanter  are  exposed.     The  insertion 
of  the  gluteus  minimus  is  thus  reached,  and  if 
necessary  it  may  be  detached.     Beneath  the 
retracted  lower  border  of  the  gluteus  medius 
there   are  now  exposed  from   above  dowai- 
wards :  the  pyriformis,  the  obturator  internus, 
the  gemelli,  and  the  upper  fibres  of  the  quad- 
ratus  femoris.    The  sciatic  vessels  and  nerves 
lie  so  far  inwards  that  they  are  not  usually 
seen.    The  tendon  of  the  pyriformis  is  de- 
tached and  retracted  upwards  or  downiwards. 
The  obturator  internus  and  the  gemelli  are 
separated  and  retracted  downwards.    Retrac- 
tion of  the  separated  muscles  exposes  the 
posterior    part    of    the    capsule.     The    head 
of  the  femur  is  made  to  project  against  the 
capsule  by  flexing,  adducting,  and  rotating 
the  limb  inwards.     The  capsule  is  incised  over  the  projecting  head  by  an 
incision  which  runs  parallel  to  the  fibres  of  the  pyriformis.     By  rotating  the 
limb  strongly  inwards  the  head  of  the  bone  is  made  to  start  out  from  the 
opening  in  the  capsule  ;  if  the  ligamentum  teres  is  intact  and  prevents  ex- 
trusion of  the  head,  it  must  be  divided.     It  now  becomes  necessary  to  divide 
the  neck  of  the  femur,   and  this  is  advantageously  done  with   a  broad 
chisel  or  gouge.     ]  laving  removed  the  head  and  neck  of  the  bone,  the  interior 
of  the  joint  is  examined  to  give  one  an  idea  of  the  extent  and  the  distribution 
of  the  disease.     The  interior  is  thoroughly  curetted  and  diseased  synovial 
membrane  removed  with  scissors.     Should  a  sequestrum  be   present  it  is 
taken  away.     Small  periarticular  foci  or  abscesses  are  liable  to  be  over- 
looked, the  interior  of  the  joint  is  therefore  carefully  searched,  and  anything 
resembling  a  sinus  o[)ening  is  enlarged  and  scraped.     The  interior  of  the 


Fig.  1'21. — Kocher's  incision  for  pos- 
terior excision  of  tlie  hiji-joint. 


248 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


joint  cavity  is  douched  wdtli  hot  sterile  lotion,  and  after  it  is  dried  a  bacteri- 
cidal paste  is  rubbed  over  the  interior.  To  fit  the  acetabulum  the  irregular 
upper  end  of  the  femur  is  rounded.  It  is  set  in  the  acetabulum  in  such  a 
way  that  the  limb  is  held  well  abducted.  The  wound  is  closed  in  different 
layers  with  interrupted  sutures  of  catgut.  A  layer  of  stitches  closes  the 
opening  in  the  capsule,  a  second  row  unites  the  gluteus  medius  to  the  pyri- 
formis  and  the  superior  gemellus,  or  the  pyriformis  to  the  superior  gemellus. 
The  third  layer  brings  together  the  split  edges  of  the  gluteus  maximus.     The 


Fio.  122. — Excision  of  the  hip  by  the  posterior  route. 


G.3f.=  Gluteus  maximus. 
r.^.  =  Vastus  externus. 
S.N.=Great  Sciatic  nerve. 


^.  =  Aponeurosis. 
Q'  P-  =  Quadratus  femoris. 
G.M.v.^  Gluteus  miuimus. 


Steps  in  the  dissection. 

=  Gluteus  medius. 

=  Gemel'.i  and  Obturator  muscles. 

-Pyriformis. 


skin  is  closed  with  interrupted  sutures  of  silkworm  gut.  As  these  stitches 
may  require  to  remain  in  position  for  two  or  three  weeks,  Stiles  ^  recommends 
that  each  suture  should  be  threaded  upon  a  piece  of  fine  rubber  tubing  about 
f  inch  long,  so  that  when  the  stitch  is  tied  the  tubitig  is  left  surromiding  that 
portion  of  the  loop  which  overlies  the  skin. 

After-treatment. — It  is  essential  in  the  after-treatment  to  secure  retention 
of  the  limb  in  the  abducted  position.  The  methods  here  described  may  be 
employed  after  any  type  of  excision,  and  therefore  these  remarks  have  a 
general  application.  After  excision  of  the  hip  it  is  expected  that  ankylosis 
will  occur  :  to  obtain  this  it  is  well  to  have  broad  osseous  surfaces  in  contact, 
and  if  the  upper  end  of  the  femur  is  well  apposed  to  the  acetabulum  and  the 
limb  carried  in  a  position  of  abduction,  the  conditions  are  ideal.     Further. 

'  stiles,  "Operations  upon  Tuberculous  Joints,"  Burghard's  Operative  Surgery,  ii.  110. 


HIP-JOINT  DISEASE  249 

there  is  the  advantage  that  when  ankylosis  is  complete,  the  part  being 
abducted,  the  Hmbs  are  easily  brought  parallel  by  dropping  the  pelvis 
upon  the  abducted  side,  and  locomotion  afterwards  is  well  carried  out.  If 
the  limb  is  kept  in  the  straight  position  after  excision,  it  will  be  found  difi&cult 
to  retain  the  upper  end  of  the  femur  in  the  acetabulum,  because  the  Umb 
has  lost  the  mechanical  fixation  which  it  had  from  the  angular  relation  of 
the  neck  to  the  shaft.  If,  under  such  conditions,  the  patient  was  to  attempt 
to  bear  any  degree  of  weight  upon  the  limb  the  end  of  the  femur  would 
become  displaced  from  the  acetabulum  and  would  pass  upwards  and  out- 
wards on  to  the  ilium.  These  mechanical  principles  have  been  investigated 
by  Stiles,  and  he  has  applied  them  in  the  after-treatment  of  his  cases. 

After  -  treatment  by  the  Abduction  SjMnt.  —  Every  precaution  must  be 
taken  to  maintain  the  hip  in  the  abducted  position  durLng  the  entire  period 
of  the  after-treatment.  For  this  pxrrpose  the  writer  (Mr.  StUes)  uses  a  simple 
but  very  effective  splint.  ...  It  is  really  a  modification  of  the  double  long 
splint  (box  spUnt)  mtroduced  many  years  ago  by  Hamilton  for  treating 
fractures  of  the  lower  extremity  in  children.  The  cross-pieces,  instead  of  being 
placed  at  the  very  end  of  the  splint,  as  in  Hamilton's,  unite  the  two  portions 
posteriorly  a  httle  above  the  heels.  The  splint  is  padded  with  wool,  and  covered 
with  jaconet  waterproof.  ...  To  convert  this  simple  splint  into  an  abduction 
splint,  two  modifications  are  necessary.  The  fu-st  is  that  the  portion  corre- 
spondmg  to  the  fliseased  side  is  sawn  across  opposite  the  hip,  and  the  two 
parts  united  by  a  common  hinge  screwed  on  to  the  outer  side  of  the  splint. 
The  other  alteration  is  that  the  two  halves  of  the  splint  are  separate  from 
each  other,  each  with  its  own  cross-piece.  The  cross-pieces  are  made  long 
enough  for  their  free  extremities  to  overlap  when  the  afiected  limb  is  abducted 
to  the  desired  degree.  To  maintain  the  abduction,  all  that  is  necessary  is  to 
fix  together  the  cross  portions  at  the  point  where  they  overlap  with  a  common 
screw  clamp.  The  upper  portions  of  the  splint  are  of  course  secured  to  the  chest 
by  a  broad  binder.  Throughout  the  subsequent  dressing  care  must  be  taken 
to  keep  the  limb  in  the  exact  position  it  occupied  while  in  the  splint,  otherwise 
there  will  be  a  great  risk  of  the  trochanter  becoming  displaced  from  the 
acetabulum.^ 

After  the  stitches  have  been  removed,  and  the  wound  is  firmly  healed, 
the  limb  is  encased  in  a  plaster  splint  which  passes  round  the  pelvis  and 
along  the  limb  as  far  as  the  ankle-joint.  The  leg  is  maintained  in  the 
abducted  position,  the  knee  is  slightly  flexed,  and  to  overcome  the  tendency 
which  there  is  for  the  plaster  to  crack  opposite  the  hip  and  knee  these  parts 
are  strengthened  by  incorporating  in  the  plaster  narrow  strips  of  aluminium. 
At  the  end  of  three  months  the  original  case  is  removed  and  a  fresh  one 
substituted,  this  second  case  remains  in  position  for  three  months.  At  the 
end  of  six  months  from  the  operation  the  plaster  is  dispensed  with  ;  a  patten 
is  fixed  to  the  opposite  boot  and  the  child  allowed  to  go  about  with  crutclies, 
no  weight  being  borne  upon  tlie  affected  limb. 

After-treatment  by  Extension. — There  are  those  who  claim  that  no  s|)lint 
is  necessary  after  operation.  They  believe  that  the  muscular  tension  around 
is  sufficient  to  keep  tiie  limb  in  position.     If  there  is  a  tendency  to  u|)Wrtrd 

'  Stiles,  loc.  sup.  cil.  vol.  ii.  p.  117. 


250  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

displacement  of  the  femur,  the  tendency  is  counteracted  by  applying  weight 
extension  in  the  long  axis  of  the  limb.  When  the  wound  is  healed  the  child 
is  fastened  upon  a  double  Thomas  splint,  and  in  this  it  is  kept  until  there 
is  sufficient  fixation  at  the  joint.  Afterwards,  the  child  is  allowed  to  go 
about,  at  first  using  crutches  with  a  patten,  afterwards  discarding  the  crutches 
and  retaining  the  patten  to  counteract  the  shortening. 

When  one  considers  the  relative  value  of  these  two  methods  of  after- 
treatment,  one  has  no  hesitation  in  recommending  the  former.  In  the  days 
which  immediately  succeed  operation,  when  there  is  often  intense  pain  on 
movement,  a  firmly  applied  and  comfortable  splint  affords  a  great  sense  of 
relief.  The  splint  further  facilitates  the  dressing,  there  is  practically  no 
risk  of  displacement  of  the  femoral  head  from  the  acetabulum,  and  there 
is  a  greater  possibility  of  a  satisfactory  ankylosis  occurring. 

Local  Curetting-  Operations. — If  there  is  an  isolated  focus  of 
tuberculous  disease  in  the  upper  end  of  the  femur  it  is  quite  feasible  to  cut 
down  upon  it  and  locally  remove  it.  It  is  unlikely  that  a  local  synovectomy 
could  be  performed  on  account  of  the  difficulty  in  gaining  free  access 
to  the  deeply  situated  joint. 

Huntington^  has  introduced  a  special  variety  of  cui-etting  operation. 
He  believes  that  in  most  cases  of  hip-joint  disease,  whether  tuberculous  or 
of  acute  infectious  origin,  the  primary  focus  is  situated  in  the  neck  or  head 
of  the  femur.  Guided  by  X-ray  examination  he  trephines  the  outer  surface 
of  the  great  trochanter  near  its  base,  and  through  the  opening  thus  made  he 
tunnels  the  neck  of  the  bone  until  the  disease  is  reached  ;  it  may  be  necessary 
to  pierce  the  epiphyseal  cartilage  and  to  enter  the  head.  The  idea  of  the 
operation  is  to  remove  the  diseased  tissue  before  it  has  extended  far  enough 
to  infect  the  synovial  membrane.  The  after  treatment  is  similar  to  that 
employed  after  excision  of  the  joint,  but,  of  course,  one  does  not  expect  the 
joint  to  become  ankylosed. 

Operations  of  Arthroplasty  in  Ankylosis  of  the  Hip-Joint 

When  the  hip-joint  is  ankylosed  in  a  deformed  position,  steps,  as 
already  described,  are  taken  to  correct  the  deformity.  It  has  been  further 
suggested  that  in  addition  to  counteracting  the  displacement,  an  attempt 
should  be  made  to  restore  some  degree  of  movement  to  the  fixed  joint.  To 
such  a  type  of  operation  the  term  arthroplasty  is  applied.  The  procedure 
briefly  consists  in  introducing  a  soft  tissue  material  between  the  ends  of 
the  bones,  in  the  hope  that  as  the  result  of  the  continual  movement  by 
the  opposing  bone  surfaces,  a  structure  which  bears  a  resemblance  to 
synovial  membrane  may  be  evolved  The  idea  originated  from  Lange- 
mak's  ^  work  on  the  origin  of  bursae.  Two  types  of  operation  will  be 
described  :  in  one,  muscle  is  used  as  the  interosseal  separation,  in  the  other 
fascias  and  fat. 

^  Huntington,  Surgery,  Gynecology,  and  Obstetrics,  ii.  406. 
-  Langemak,  Archiv  fur  klin.  Chir.,  Ixx.  p.  946. 


HIP-JOINT  DISEASE  251 

Nelaton's  Operations  with  the  Introduction  of  Muscle  between 
the  Cut  Surfaces  of  the  Bone. — An  incision  6  inclies  long  is  made  along 
the  anterior  border  of  the  great  trochanter,  it  begins  about  1  inch  below 
the  anterior  superior  spine  of  the  Uium.  The  muscular  iaterspace  between 
the  tensor  fasciae  femoris  and  tlie  sartorius  is  opened  up  to  expose  the 
rectus  femoris  and  more  deeply  the  ilio-psoas.  The  two  last-named  muscles 
are  retracted  inwards  to  expose  the  anterior  surface  of  the  articular  capsule. 
The  capsule  is  split  from  the  anterior  inferior  iliac  spine  to  the  trochanter, 
care  being  taken  to  retain  the  ilio-femoral  ligament  as  complete  as  possible. 
The  anterior  surface  of  the  neck  of  the  femur  is  exposed  with  the  junction 
of  ankylosis  between  thigh  bone  and  acetabulum.  Using  a  broad  osteotome 
the  neck  of  the  femur  is  divided  close  to  the  pelvis,  and  the  site  of  the  aceta- 
bulum is  made  concave  and  smooth  by  means  of  gouge  and  rongeur.  The 
divided  neck  is  rounded  off  to  fit  the  acetabulum.  A  layer  of  muscle  is  now 
interposed  between  the  new  articulating  surfaces,  the  muscle  being  obtamed 
by  dividing  the  rectus  femoris  4  inches  below  its  origin  and  fixing  the  upper 
end  in  the  new  acetabular  cavity  with  a  few  catgut  sutures.  The  femur  is  set 
in  position  and  kept  in  place  until  the  wound  heals.  Exercises  are  begun  early 
and  gradually.  If  there  is  much  inversion  of  the  thigh  it  may  be  impossible 
to  employ  an  anterior  incision,  under  such  conditions  an  external  incision  is 
used,  and  the  muscle  flap  is  obtained  from  one  of  the  gluteal  muscles. 

Murphy's  Operation  ^  with  the  Introduction  of  Fascia  and  Fat 
between  the  Ends  of  the  Bones. — A  v-shaped  incision  is  used.  The 
trochanter  occupies  the  centre  of  the  V,  the  open  end  of  which  measures  5 
inches.  Vertically  the  incision  extends  from  a  point  4  inches  above  to  a 
point  2  inches  below  the  trochanter.  The  flap  thus  outlined  is  dissected 
upwards ;  it  consists  of  skin,  superficial  fascia,  and  fascia  lata.  The  outer 
surface  of  the  trochanter  major  is  cleared,  a  Gigli  saw  is  passed  round  its 
base  and  the  trochanter  divided  at  its  attachment  to  the  femur.  The 
separated  trochanter,  carrying  the  muscles  which  are  inserted  into  it,  is 
retracted  upwards.  The  remains  of  the  articular  capsule  are  incised  and 
separated  from  the  edge  of  the  acetabulum.  The  ankylosis  between  the 
femur  and  the  pehas  is  separated,  and  in  doing  so  the  bone  is  cut  away 
from  the  acetabulum  so  that  a  rounded  surface  is  left  upon  the  femoral  head, 
while  the  cotyloid  ca^nty  is  of  considerable  depth.  From  the  deep  surface 
of  the  original  flap  the  fascia  lata  is  separated,  being  left  attached  above. 
It  is  made  to  line  the  acetabulum,  and  it  is  fixed  in  position  with  a  few 
interrupted  catgut  sutures.  As  only  the  base  of  the  fascial  flap  is  reciuired 
for  this  purpose,  the  apical  portion  is  used  to  cover  over  the  head  of  the 
femur.  Murphy  insists  upon  the  importance  of  covering  every  portion  of 
the  opposed  bone  with  the  fascial  covering.  The  head  of  the  femur  is 
manipulated  into  the  deepened  acetabulum,  and  the  separated  trochanter 
is  brought  back  and  wired  in  position.  The  skin  wound  having  been  closed 
the  limb  is  kept  in  extension  until  the  parts  are  healed,  movements  are  then 
commenced. 

'  Murphy,  Journ.  Amer.  Med.  Assoc,  May  20,  27,  .June  ;t,  I'JO."). 


252  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

After  Results  of  Excision  of  the  Hip.— During  the  years  1901-1911 
there  have  been  59  excisions  of  the  hip  performed  in  the  Edinburgh  Sick 
Children's  Hospital.  These  operations,  which  were  performed  by  Mr. 
Stiles,  have  been  embodied  in  a  recent  paper.^  The  average  age  at  the  time 
of  operation  was  5|  years  ;  33  were  below  6  years  and  26  between  6  years  and 
12.  Eighteen  months  was  the  average  duration  of  the  disease  before  opera- 
tion was  carried  out.  In  the  immediate  post-operative  results,  that  is  to  say 
in  the  period  before  the  child  was  discharged  from  hospital,  there  were  only 
two  deaths,  both  the  result  of  tuberculous  meningitis.  Within  six  months 
after  operation  9  cases  had  succumbed  to  general  tuberculosis,  and  within 
eighteen  months  another  child  had  succumbed  from  the  same  cause.  There- 
fore, eighteen  months  after  operation  there  was  a  total  mortality  of  12." 
all  due  to  a  dissemination  of  the  disease.  As  regards  the  usefulness  of  the 
limb,  observations  were  made  upon  40  cases,  the  post-operative  period  varying 
in  time  from  ten  years  to  eighteen  months.  In  19  instances,  that  is  to  say 
in  50  per  cent  of  the  investigated  cases,  the  results  of  the  excision  could  be 
classified  as  good.  The  general  health  was  excellent,  the  hip  ankylosed, 
no  sinuses,  the  scars  completely  decolorised,  and  a  very  moderate  deformity 
of  shortening  and  flexion.  The  degree  of  shortening  averaged  If  inches, 
an  amount  easily  corrected  by  heightening  the  sole  of  the  boot.  In  3  cases, 
there  was  such  an  extensive  recurrence  of  the  disease  that  it  was  found 
necessary  to  perform  disarticulation  of  the  hip.  Five  cases  retiuned  with 
slight  recurrence  of  the  disease  necessitating  and  cured  by  further  operation.  • 

It  may  be  stated  then,  in  brief,  that  the  post-operative  results  of  hip 
excision  are  wonderfully  good  when  it  is  remembered  that  the  operation  is 
performed  when  the  disease  is  well  advanced  and  often  as  a  life-saving 
measure.  The  secret  of  success  is  that  when  the  operation  is  performed, 
it  must  be  carried  out  thoroughly,  an  incomplete  operation  is  worse  than 
useless  as  it  stimulates  and  aggravates  the  disease  which  is  left.  The  dis- 
advantages usually  quoted  are  those  of  ankylosis  and  shortening.  Ankylosis, 
when  it  is  unilateral,  is  no  great  encumbrance,  it  certainly  interferes  very 
little  with  progression.  Shortening  is,  of  course,  a  more  formidable  draw- 
back, but  as  long  as  it  is  not  excessive  it  can  be  compensated. 
ii^  Operative  Dislocation  of  the  Hip. — In  the  natural  cure  of  hip-joint 
disease,  one  sometimes  finds  that  the  head  is  pushed  out  of  the  acetabulum, 
and  the  fact  that  the  diseased  surfaces  are  not  now  in  apposition,  a23pears  to 
improve  the  prospect  of  eventual  cure.  Bradford  and  Lovett  suggested  that 
this  process  might  be  imitated  in  operating  practice,  and  in  3  cases  of  advanced 
disease  it  was  practised.  The  femoral  head  is  exposed  as  in  excision,  and 
the  carious  surfaces  curetted  and  wiped  with  alcohol.  The  head  is  dislocated 
on  to  the  dorsum  ilii,  and  after  drainage  has  been  secured  and  the  wound 
closed  the  limb  is  fixed  in  a  position  of  flexion  and  adduction.  When  cure 
is  complete  the  adduction  of  the  ankylosed  hip  can  be  treated  by  a  correcting 
osteotomy.    In  three  cases  operated  on  by  the  originator,  one  died  six  months 

1  Stiles,  Brit.  Med.  Journ.,  November  16,  1912. 
'  Only  forty  cases  traced. 


HIP-JOINT  DISEASE  253 

later  of  waxy  disease,  in  the  second  the  ultimate  result  could  not  be  ascer- 
tained, the  third  recovered  completely,  and  ten  years  later  was  strong  and 
well  with  a  serviceable  limb  which,  though  flexed  and  adducted,  could  easily 
be  restored  to  proper  position  by  an  osteotomy. 

Amputation. — The  question  of  amputation  or  disarticulation  of  the 
diseased  limb  remains  for  consideration.  The  operation  is  indicated  in 
those  cases  in  which  (1)  the  disease  is  steadily  progressive  ;  (2)  there  are 
numerous  sinuses  and  extensive  superficial  ulceration  ;  (3)  the  disease  is 
extensively  involving  the  pelvic  bones ;  (4)  the  general  health  is  seriously 
affected,  and  the  prolonged  suppuration  is  giving  rise  to  amyloid  disease. 
It  is  important  that  the  operation  should  not  be  delayed  too  long  The 
most  absolute  economy  must  be  exercised  in  permitting  the  loss  of  blood, 
as  these  cases  are  often  reduced  to  the  last  extremity  by  the  ravages  of  the 
original  disease. 

The  difficulty  of  the  operation  lies  in  the  method  of  controlling  the 
femoral  artery.  The  limb  may  be  elevated  and  stripped  of  blood,  and  the 
artery  controlled  by  an  elastic  band  or  tourniquet.  This  band  passes  behind 
the  thigh,  between  the  tuber  ischii  and  the  anus  ;  in  front  it  passes  over  the 
vessels  where  it  exerts  pressure  through  the  medium  of  a  roller  bandage 
placed  beneath  it.  The  ends  of  the  tourniquet  are  drawn  tightly  upwards 
and  outwards  to  a  point  above  the  centre  of  the  iliac  crest.  They  are  held 
in  place  by  an  assistant,  and  the  bleeding  from  both  femoral  and  internal 
iliac  sources  is  controlled. 

Haemorrhage  may  be  dealt  with  by  means  of  Wyeth's  pins.  The  thigh 
is  transfixed  with  these  from  side  to  side  above  the  incision,  and  pressure  is 
exerted  by  passing  stout  rubber  tubmg  around  the  ends  of  the  skewers  in 
front  of  and  behind  the  thigh. 

Lastly,  the  bleeding  may  be  minimised  by  ligaturing  the  femoral  vessels 
preliminary  to  removing  the  limb.  In  the  presence  of  sinuses,  flaps  should 
be  planned  which  avoid  these.  It  is  also  of  importance  to  take  care  that  the 
wound  lies  if  possible  upon  the  outer  side  of  the  limb,  and  so  removed  from 
the  danger  of  an  anal  infection. 

When  the  pelvis  is  diseased,  it  may  be  necessary  to  remove  large  portions 
of  the  ilium,  the  ischium,  and  pubis.  This  should  be  done  as  completely 
as  possible  to  lessen  the  chance  of  a  recurrence  of  the  disease. 

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Hrp-JoiNT  Disease 

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1909,  173-185. 
Saabfils.     "  Uber  Coxitis,"  St.  Petersb.  med.  Wochenschr.,  1909,  xxxiv.  89-91. 
Cayre,  E.     "  Les  Coxalgies  douloureuses  rebelles,"  CUnique,  Paris,  1909,  iv.  86-90. 
Kjrmisson.     "  Les  Recidives  de  la  coxalgie,"  Rev.  gen.  de  din.  et  de  therap.,  Paris,  1909, 

xxiii.  566. 
Mitt,  J.  J.     "  A  Device  for  Measuring  Flexion  Deformity  in  Hip  Joint  Disease,"  J.  Am. 

M.  Ass.,  Chicago,  1909,  In.  382. 
Larny,  L.     "  Coxalgie  gauche  chez  un  enfant  de  3  ans,  etc.,"  Rev.  d'orthop.,  Paris,  1909, 

2"  ser.  X.  367-371. 
FioLLE  and  Barbe.     "  Sur  les  attitudes  vicieuses  de  la  coxalgie,"  Marseille  med.,  1909, 

xlvi.   712-718. 
Sexton,  L.     "  Observations  on  Tubercular  Hip-joint  Disease,"  N.  Orl.  31.  and  Surg.  J., 

1909-10,  Ixii.  633-638. 
Gallie,  W.  E.     Tuberculosis  of  the  Hip-joint,  Canada,  London,  Toronto,   1909-10,  xliii. 

337-341. 
Steishabdt,  I.  D.     "  Tuberculosis  of  the  Hip-joint,"  N.   York  3I.J.,  1910,  xci.  803-807. 
Aemstrong,  G.  E.     "  Tuberculosis  of  the  Hip,"  Ann.  Surg.,  Philadclpliia,  1910,  U.  520-523. 
Wyeth,  J.  A.     "A  Case  of  Hip-joint  Disease,"  3Ied.  Rec,  New  Yorls,  1910,  Ixxvii.  707.. 
M'MuRPHY,  N.  W.     "  Tuberculous  Hip  Disease,"   3Ied.  Progress,  Louisville,   1910,  xxvi. 

27-31. 
Sexton,  L.     "  Observations  on  Tubercular  Hip-joint  Disease,"   Virginia  31.  Semi-3Ionth., 

Richmond,  1909-10,  xiv.  133-135. 
Rowlands,  R.  P.     "  Tuberculous  Disease  of  the  Hip-joint,"  Guij's  Hosp.  Gaz.,  London,  1910, 

xxiv.  421-425. 
Liebenthal      "  Tuberculosis  of  the  Bones  and  Joints  of  the  Lower  Extremity,"  N.  York 

31.  Journ.,  Ixxxvi.  1200-1202. 
Jankooski,    I.    I.     "  Chronic    Hip-joint   Disease    caused   by   Pyogenic   microbes  and  its 

comphcations,"  Khirurg.  Arkh.  Vebyaminova,  St.  Petersburg,  1910,  xxvi.  1049-1056. 
Kirmisson,  E.     "  Forme  fruste  ou  anormale  de  la  coxalgie,"  Bull.  Acad,  de  Med.,  Paris,  1910, 

Ixiv.  51-55. 
Mencieeb,  L.     "  fitude  cinematographique  du  mouvement  dans  la  guerison  de  la  coxalgie 

et  des  tumeurs  blanches,"  Pediatric  prat.,  LiUe,  1910,  viii.  371-373. 
Beoca,  A.     "  Tuberculose  de  la  rotule,   hydrarthrose  tuberculeuse  du  genou,"  Rev.  prat. 

d'obst.  et  de  pediat.,  Paris,  1910,  xxiii.  97-108. 
Eheinghatjs,  O.     "  Zur  Atiologie  der  Knochenatrophie  bei  tuberkuloser  Koxitis,"  Charitc- 

Ann.,  Berlin,  1910,  xxxiv.  755-761. 
KiEMissoN.     "  L'Inversion  dans  la  coxalgie,"  Revue  internal,  de  med.  et  de  chir.,  Paris,  1910, 

xxi.  63-65. 
Kjrmisson.     "  La  Coxalgie  avec  adduction,"  Pediatrie  prat.,  LUle,  1910,  viu.  76-80. 
Ray,  J.  H.     "  The  Surgical  Affection  of  the  Hip-joint  in  Infancy  and  Childhood,"  3Ied. 

Chir.,  1911,  Hv.  249-271. 
Smith,  E.  H.     "  Tuberculosis  of  the  Hip,"  Pacific  M.J.,  San  Francisco,  1911,  liv.  412-414. 
Campbell,  W.  C.     "  Chronic  Affections  of  Hip,"  Memphis  3Ied.  3Ionth.,  1911,  xxxi.  287-292. 
D'Antona,  a.     "La  Coxite  tubercolare,"  Studien,  Napoli,  1911,  iv.  95-98. 
Schlee,  H.     "  Coxitis  tuberculosa,"  Med.  Klin.,  Berlin,  1913,  ix.  339. 
Geeaed,  C.  M.     Des  differentes  varietes  cliniques  et  anatomiques  (radiographic)  des  affections 

tnberculeuses  de  la  hanche,  Nancy,  1912. 
Elmslie,  R.  C.     "  Three  Cases  of  an  Uiuisual  Form  of  Disease  of  the  Hip-joint :  Calve's 
Pseudo-coxalgie,"  Proc.  Roy.  Soc.  3Ied.,  London,  1912-13,  Children's  Sect.,  102-106. 


HIP-JOINT  DISEASE  255 

Diagnosis 

Jacobs,  C.  M.     "  Symptoms  and  Differential  Diagnosis  of  Tubercular  Hip-joint  Disease," 

Quart.  Bull.  North-west  Univ.  Med.  Sch.,  Chicago,  1908-9,  x.  80-84. 
OsTERHAM,  K.     "  Diagnosis  and  Treatment  of  Coxalgia,"   Virginia  M.  Semi-Month.,  Rich- 
mond, 1908,  xiii.  78-82. 
Marshall,  V.  F.     "  Concerning  the  Diagnosis  and  Treatment  of  Hip-joint  Disease,"  Wis- 
consin M.J.,  Milwaukee,  1908-9,  vii.  399-409. 
Salaghi,  M.     '■  Nuovo  Segno  per  la  diagnosi  iniziale  deUa  coxite,"  Arch,  di  orlop.,  Milano, 

1908,  XXV.  262-266. 
Calve,  J,     "  Difficultes  du  diagnostic  de  la  coxalgie  au  debut,"  Presse  med.,  Paris,  1909, 

xxii.  122-125. 
Shands,  a.  R.     "  The  Diagnosis  and  Treatment  of  the  Early  Stages  of  Hip  Disease,"  Virginia 

M.  Semi-Month.,  Richmond,  1909-10,  xiv    121-125. 
Steen,  W.  G.     "  The  Diagnosis  of  Tuberculous  Hip-joint  Disease,"  Cleveland  M.J.,  1909, 

viii.  686-696. 
Savariana.     "  Co.xalgie  fruste  simulant  la  coxa  vara  des  adolescents,"  Bull,  et  mem.  Sac. 

de  Chir.  de  Par.,  1910,  N.S.  xxxvi.  891-895. 
Maire.     "  Diagnostic  et  traitement  de  la  coxalgie  au  debut,"  Centre  med.  et  pharm.,  Gannat 

1909-10,  .XV.  291-305. 
Walderstroom,  H.     "  Die  Herdreaktion  auf  Tuberkulin  bei  der  Koxitis,"  Zeitschr.  fiir  orlh. 

Chir.,  Stuttgart,  1910,  xxvi.  623-642. 
Forbes,  A.  M.     "  The  Condition  of  the  Lymphatic  Glands  as  a  Factor  in  the  Diagnosis  of 

Tuberculosis  of  the  Hip  and  Lower  Spine,"  Montreal  M.J.,  1910,  xxxix.  518-526. 
DucROQUET,  C.     "  Le  Diagnostic   de  la  coxalgie,"  Rev.  d'hyg.  et  de  med.  inf.,  Paris,  1910 

ix.  482-491. 
Jacobs,  C.  M.     "  Symptoms  and  Differential  Diagnosis  of  Tuberculous  Hip-joint  Disease," 

Iowa  M.J.,  Des  Moines,  1910-11,  xvii.  555-560. 
KiRMissoN,  K.     "  Sur  un  point  particulier  de  I'histoire  de  la  coxalgie  double,"  Rev.  d'orthop., 

Paris,  1910,  d"  ser.  i.  559-562. 
Mauclaire.     "  Symptomes,  diagnostic  et  traitement  de  la  coxotuberculose,"  J.  de  med.  int-, 

Paris,  1910,  xiv.  91. 
Bboca.     "  Le  Diagnostic  de  la  coxalgie  au  debut,"  Pediatric  prat.,  Lille,  1911,  ix.  1-6. 
Savariana.     "Coxalgie  au  debut:   diagnostic  et  traitement,"  Med.  inf.,  Paris,  1911,  viii 

32-37. 
RociiER,  H.  L.     "  Le  Signe  de  la  clef  dans  la  coxalgie  au  debut,"  Gaz.  hebd.  des  sc.  med.  de 

Bordeaux,  1912,  xxxiii.  608. 

Treatment 

Lannelonotje.     "  Traitement  de  la  coxotuberculose  dans  la  phase  de  debut,"  Bull.  Acad. 

de  Med.,  Paris,  1907,  3«  ser.  IvUi.  595-601. 
M'Ilhenny,  p.  a.     "  The  Treatment  of  Coxitis,"  X.  Orl.  M.  and  S.J.,  1907-8,  Ix.  635-643. 
Bradford,  E.  H.,  and  Soutter,  R.     "  Traction  in  the  Treatment  of  Hip  Disease,"  Am. 

J.M.  Sc,  Philadeli)hia  and  New  York,  1908,  N.S.,  cxxxvi.  794-818. 
GiBENEY,  H.     "  Some  Observations  on  the  Treatment  of  Hip  Disease,"  Virgin.  M.  Semi- 
Month.,  Richmond,  1908-9,  xiii.  529-531. 
Calot.     "  Co  qui  doit  etre  lo  traitement  do  la  coxalgie,"  Bull.  mid.  de  Quebec,  1908-9    x 

481-490. 
Marion,  G.     "Traitement  de  la  coxalgie,"  Rev.  internat.  de  mid.  et  de  chir.,  Paris,  1908 

xix.  143-145. 
Wynkoop,  E.  J.     "  The  Use  of  Traction  in  the  Treatment  of  Hip-joint  Disease  in  Children," 

Arch.  Pediat.,  New  York,  1908,  xxv.  198-202. 
ViLLEMiN.     "  Traitement  de  la  coxalgie,"  Bull,  med.,  Paris,  1908,  xxii.  77-83. 
Abbott,  E.  G.,  and  Popohe,  H.  A.     "  The  Ambulatory  Treatment  of  Hip-joint  Disease," 

Med.  J.  Am.  Med.  Ass.,  1908.  i.  427-432. 
Wills,  W.  Le  M.      "Treatment  of  Uip-joint  Disease,"  Calif.  State  J.M.,  San  Francisco, 

^1908,  vi.  22-24. 
Calot.     "  Lo  Traitement  de  la  coxalgie,"  liev.  gen.  de  din.  et  de  thcrap.,  Paris,  1908   xxii 

161-168. 
Hoffa,  A.     "  Die  Behandlung  der  tuberkuloscn  Koxitis,"  Monataschr.  f.  orlhop.  Chir.,  Berlin, 

1908,  viii.  1-3. 
Rankin,  H.  B.     "  Hip  Disease  :  the  Responsibilities  of  the  Surgeon  and  the  Indications  for 

Treatment,"  Quart.  Bull.  North-West  Univ.  Med.  Sch.,  Chicago,  1908-9,  x.  51-54. 
Villemin.     "  Traitement  do  la  coxalgie,"  Ann.  de  mid.  et  chir.  inf.,  Paris,  1908,  xii.  80-100. 


256  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

Babkakin,  p.     "  L'Appareil  platre  dans  la  coxalgie  chez  I'enfant,"  Clinique,  Paris,  1908 

iii.  529-532. 
Bareabian,  p.     "  Traitement  de  la  coxalgie  sans  abces  et  sans  attitude  vicieuse,"  Clinique. 

Paris,  1908,  iii.  313. 
GiBNEY,  V.  P.     "  The  Influences  of  Weight-bearing  on  the  Treatment  of  Tuberculous  Hijj- 

joint  Disease,"  Amer.  Journ.  Orth.  Surg.,  1908-9,  vi.  21-34  and  128-132. 
Benoit,  C.    "  Evolution  du  traitement  de  la  coxalgie,"  Fediatrie  prat.,  LUle,  1908,  vi.  229-234. 
ViONARD.     "  Tuteur  a  point  d'appui  ischiatique  jjoui   coxalgie  guerie,"  Lyon  mid.,  1908, 

cxi.  464-470. 
BiDATjx,  R.     "  Etudes  sur  lo  traitement  de  la  coxalgie,"  Rev.  internal,  de  la  tuberc,  Paris, 

1909,  xvi.  403-409. 
Weber,  H.     "  tjber  die  Behandlung  der  Kontrakturen  tuberculoser  Hiiftgelenke,"  Arch. 

f.  Orthop.,  Wiesbaden,  1909,  viii.  193-197. 
WiLCHET,  J.     "  A  propos  do  !a  coxalgie  et  de  son  traitement  local  conservateur,"  Scalpel, 

Liege,  1909-10,  Ixii.  241-253. 
Von  Bonsdorfe,  H.     "  The   Surgical  Treatment   of  Tuberculous  Coxitis,"  Finska  Labr. 

Sallsk.  Handl,  Helsingfors,  1909,  li.  v.  2.  901-921. 
Delchef,  J.     "  Technique  de  la    methode  de  Lorenz  pour  le  traitement  de  la  coxalgie," 

Scalpel,  Liege,  1909-10,  Ixii.  635-641. 
BiDAUX,  K.     "  Traitement  regulier  d'un  coxalgie  prise  au  debut,"  Rev.  internal,  de  la  tuberc. 

Paris,  1909,  xv.  414-425. 
Maybt,  H.     "  Comment  faut-il  traiter  la  coxalgie?"  Rev.  metis,  de  gynec,  d'obstet.  et  de  pediai., 

Paris,  1909,  iv.  155-lGl. 
Savaeiana.     "  Appareils  platres  dans  la  coxalgie,  etc.,"  Jour,  de  med.  de  Paris,  1909,  2e. 

ser.  xxi.  223-225. 
ScHWATT.     "  The  Treatment  of  Abscesses  in  Hip  Disease,"  Internal.   Clin.,  Philadelphia, 

1909,  19.  n.  U.  177-189. 

Wilson,  H.  A.     "  Treatment  of  Tuberculous  Hip  by  Weight-bearing  and  Fixation  by  the 

Lorenz  Short  Hip  Spica,"  South  M.J.,  Nashville,  1909,  ii.  440-444. 
Belham.     "  Coxalgie :  quelques  notes  sur  son  traitement,"  Ann.  de  chir.  et  d'orlhop.,  Paris, 

1910,  xxiii.  321-326. 

Belham.     "Quelques  notes  sur  le  traitement  de  la  coxalgie,"  Ann.  de  chir.  et  d'ortho'p., 

Paris,  1910,  xxiii.  353-358. 
ViGNABD.     "  Traitement  de  la  coxalgie  avec  plombage,"  Lyon  med.    1910,  cxiv.  637. 
Mencibee,  C.     "  Technique  du  traitement  de  la  coxalgie  et  des  tumeurs  blanches  pour  la 

conservation    du    mouvement    dans   I'articulation,"  Arch.  prov.  de  chir.,  Paris,   1910, 

xix.  135-171. 
Hendrex,   G.     "  Le  Traitement  de  la  coxalgie  par  la  methode  conservatrice  do  Lorenz,"' 

Policlinic,  Brux.,  1910,  xix.  65-75. 
Neuber,  G.     "  tJber  die  Behandlung  der  tuberculosen  Koxitis,"  Archiv  f.  Iclin.  Chir.,  Berlin, 

1910,  xciii.  96-118. 

Hendrex.     "  Un  Cas  de  coxalgie  traite  par  la  methode  ambulatoire,"  Policlin.,  Brux.,  1910, 

xix.  201-203. 
Alapy,   H.       "  Die  Endergebnisse   der   konservativen    Coxitis-   und    Gonitis-Behandlung," 

Zeitschr.f.  orth.  Chir.,  Stuttgart,  1910,  xxvii.  243-278. 
DooHE,  J.     "  Prognostic  et  traitement  de  la  coxalgie  fistulee,"  J.  de  mid.  de  Bordeaux,  1910, 

xl.  561-563. 
Menciere,  L.     "  Technique  du  traitement  de  coxalgie,  etc.,"  Pediatric  prat.,  LiUe,  1910, 

viii.  366-371. 
Murphy',  T.  B.     "  Lesions  of  the  Hip-joint  and  their  Management,"  Surg.  Gyn.  and  Obstr., 

1911,  xii.  200. 

Calve,  J.  "  Quelques  considerations  sur  les  appareils  amovibles  en  celluloid  dans  le  traite- 
ment de  la  coxalgie  et  du  mal  de  Pott,"  Clinique,  Paris,  1911,  vi.  241-244. 

Feiss,  H  D.  "  Treatment  of  Hip  Disease  as  based  on  its  pathological  Mechanics,"  Ohio 
M.J.,  1911,  165-169. 

CoNDEAY,  P.     "  Coxo-tuberculose  et  son  traitement,"  Rev.  de  chir.,  Paris,  1911,  xliii.  420-467. 

Snively,  J.  H.     "  Extension  Apparatus  for  Hip-joint  Disease,"  North-west  Med.,  Seattle, 

1912,  N.S.,  iv.  269. 

Keppler,  C.  B.     "  The  Short  Spica  in  the  Treatment  of  Hip-joint  Disease,"  Am.  J.  Obst. 

New  York,  1912,  Ixvi.  888-892. 
Keppler,  C.  R.     "The  Short  Spica  in  the  Treatment  of  Hip-joint  Disease,"  J.  3Ied.  Soc, 

New  Jersey,  Orange,  1912-13,  ix.  599-603. 
Packard,  G.  B.     "The  Mechanical  Treatment  of  Hip  Disease,"  Amer.  Journ.  Orth.  Surg.. 

1912-13,  X.  329-332. 


HIP-JOINT  DISEASE  257 

Bradford,  E.  H.      "  Fixation    in   the   Treatment   of   Hip    Disease,"  Amer.  Journ.  Ortli. 

Surg.,  1912-13,  x.  354-362. 
Taylor,  H.  L.     "  Results  in  Hip  Tuberculosis  after  Mechanical  Treatment  without  Traction 

and  Hygiene,"  Amer.  Journ.  Orth.  Surg.,  1912-13,  x.  333-353. 

Operative  Treatment 

Berry,  W.  T.     "  Some  Thoughts  on  Resection  of  the  Hip-joint  for  Tuberculous  Disease," 

Charlotte  {N.C.)  M.J.,  1907,  xxxi.  293-299. 
RoOTH,  H.  C.     "  Radical  Operation  for  the  Cure  of  Incipient  Hip-joint  Disease,"  Buffalo 

M.J.,  1908-9,  Ixiv.  594.     . 
M'BuRXEY',  C.     "  Amputation  at  the  Hip-joint  for  Tuberculosis,"  Med.  Rec,  New  York, 

1908,  Ixxiii.  667. 
ViGNARD.      "  De   I'osteotomie   sous-trochanterienne  et  sous-cutanee  dans   le   redressement 

des  attitudes  vicieuses  de  la  coxalgie  gueric,"  Bull.  Soc.  de  Chir.  de  Lyon,  1908,  xi.  24-27, 
ViGNARD.     "  De  I'osteotomie  sous  trochanterienne  et  sous  cutanee  dans  le  redressement 

des  attitudes  vicieuses  de  la  coxalgie  giierie,"  Lyon  Med.,  1908,  ex.  494-497. 
Jeanne  and  Fortin.     "  La  Desarticulation  de  la  hanche  dans  les  vieilles  coxalgies  fistuleuses," 

Rev.  mid.  de  Normandie,  Rouen,  1908,  446-448. 
BowLBY,  A.  A.     "An  Address  on  900  Cases  of  Tuberculous  Disease  of  the  Hip  .  .   .  with  a 

Mortality  of  less  than  4  per  cent,"  B.M.J.,  1908,  i.  1465-1469. 
KoNio.     "  Die  operative  Entfernung  (Resektion)  des  tuberkulos  erkranktcn  Hiiftgelenks," 

Berl.  klin.  Wochen.'iclir..  1909,  .xlvi.  429-431. 
De  Beule,  F.     "  Huftgelenks-Resektion,"  Zentralbl.  f.  Chir.,  Leipzig,  1909,  xxxvi.  1077. 
Vignard.     "  Deux  cas  dc  coxo-tuberculoso  grave   traites  par  la  resection  suivie  de  plom- 

bages,"  Lyo7i  mid..  1909,  cxii.  112-115. 
Greenbero,  H.  J.     "  Resection  for  Tuberculosis  of  the  Hip-joint,"  Wisconsin  Med.  Journal, 

Milwaukee,  1909-10,  viii.  448-463. 
ViNANT,  E.     "Notes  sur  la  coxalgie  et  la  resection  de  la  hanche,"  Puris  chirurg.,  1909, 

i.  712-722. 
Herman  and  Maffei      "  La  Resection  de  la  hanche  dans  la  coxalgie,"  J.  de  chir.  el  Ann. 

Soc.  beige  de  Chir.,  Brux.,  1909,  ix.  229-237. 
Calot,  F.     "  Les  Injections  articulaires  dans  le  traitement  de  la  coxalgie,"  Rei:  de  med. 

et  de  chir.,  Paris,  1910,  viii.  48-57. 
Ingram,  J.  W.     "  Hip-joint  Amputation  in  Complicated  Tuberculous  Hip-joint  Disease," 

Med.  Sentinel,  Oregon,  1910,  xvii.  100-102. 
Binet,  A.     "  La  Resection  dans  la  coxalgie,"  Rev.  mid.  d'esi,  Nancy,  1910,  xliii.  513. 
CoNDRAY,  P.     "  Traitement  operatoire  et  traitement  conservateur  dans  la  coxalgie  infantile," 

Oaz.  mid.  de  Paris,  1911,  Ixxxii.  153. 
OoiLVY',  ( '.     "  The  Results  of  Excision  of  the  Hip  in  Tuberculosis  of  the  Joint,"  Post  Qraduate, 

New  York,  1912,  xxvii.  989-998. 


17 


258 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT 

Etiology 

Tuberculosis  of  the  knee  is  essentially  a  disease  of  early  life,  although 
it  is  less  strictly  confined  to  childhood  than  disease  of  the  hip  and  spine. 
As  in  tubercle  afEectiug  other  joints  there  is  often  the  history  of  injury 
preceding  the  development  of  the  disease,  and  from  the  exposed  position 
of  the  knee  it,  of  course,  is  specially  liable  to  various  kinds  of  injuries.  There 
is  also  very  often  the  previous  history  of  one  of  the  exanthemata.  The 
disease  occiu-s  almost  equally  in  the  two  sexes.  The  other  etiological  factors 
are  similar  to  those  discussed  in  other  joints. 


Pathology 

Anatomy  of  the  Joint. — The  knee  is  the  largest  joint  in  the  body.     The 
strength  and  numbers  of  its  ligaments  make  it  one  of  the  strongest  also.     A 

distinctive  feature  of  the  joint  is  the  presence 
in  its  Ulterior  of  ligaments  (crucial)  and  cartil- 
ages (semi-lunar).  The  synovial  membrane 
forms  a  large  surface.  Its  upper  limit  extends 
about  three  finger-breadths  above  the  upper 
border  of  the  patella  ;  laterally  it  covers  the 
anterior  thud  of  the  outer  surface  of  each  con- 
dyle, posteriorly  there  is  no  extension  upwards 
above  the  condyles.  The  lower  limit  extends 
anteriorly  and  laterally  as  far  as  the  upper 
border  of  the  tibia  ;  posteriorly  it  dips  down- 
wards for  a  short  distance  behind  the  popliteal 
notch  of  the  tibia  to  form  a  cul-de-sac.  The 
membrane  lines  the  capsule,  the  deep  aspect 
of  the  infrapatellar  pad  of  fat,  and  both 
surfaces  of  the  semi-lunar  cartilages.  It  forms 
an  almost  complete  investment  for  the  crucial 
ligaments  and  the  tendon  of  the  popliteus. 
The  upper  synovial  reflexion  extends  on  to  the 
metaphysis  of  the  femiu  in  front ;  laterally  and  posteriorly  it  does  not 
extend  beyond  the  epiphysis.  The  majority  of  the  vessels  communicating 
between  the  synovial  tissues  and  the  bone  enter  posteriorly  and  therefore 
enter  the  epiphysis.  Below,  both  synovial  reflexion  and  blood-vessels  Ue  in 
relation  to  the  epiphysis. 


m 

Fig.  123.— The  knee-joint. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT  259 

Pathological  Anatomy. — The  first  question  which  arises  in  pathology 
is  that  of  whether  the  disease  is  primarily  osseous  or  primarily  synovial. 
Some  have  stated  that  in  childhood  the  disease  is  primarily  an  epiphysitis 
commencing  in  the  head  of  the  tibia  or  the  lower  end  of  the  femur  and  rarely 
in  the  patella  or  fibula.  The  experience  of  others  has  been  that  the  disease 
starts  more  frequently  in  the  synovial  membrane  than  in  the  bone,  and  with 
this  view  the  author  agrees. 

When  a  secondary  osseous  focus  occurs,  it  is  more  common  to  find  it 
in  the  lower  end  of  the  femur  than  in  the  tibia  or  patella,  and,  speaking  more 
exactly,  the  epiphysis  of  the  femur  is  more  commonly  affected  than  the 
metaphysis.  The  explanation  of  the  location  is  dependent  upon  the  arrange- 
ment of  the  overlymg  synovial  membrane,  more  especially  the  reflexion  of 
the  membrane  and  the  circus  vasculosus.  The  vessels  which  pass  from  the 
synovial  membrane  into  the  femur  lie  almost  entirely  upon  the  posterior 
surface,  a  few  pierce  the  lateral  parts  and  a  few  enter  in  front.  The  upper 
reflexion  of  the  synovial  membrane  posteriorly  does  not  extend  above  the 
epiphyseal  cartilage,  it  lies  entirely  in  relation  to  the  epiphysis.  Therefore, 
with  these  facts  before  one,  it  is  easy  to  understand  why  tuberculous  lesions 
at  the  lower  end  of  the  femur,  secondary  to  synovial  disease,  are  epiphyseal 
and  so  rarely  metaphyseal.  If  the  anatomical  reflexion  of  the  synovial 
membrane  extends  to  the  metaphysis  the  bone  lesion  is  in  all  probabiUty 
a  metaphyseal  one.  The  more  intimate  pathology  dealing  with  the 
changes  in  the  synovial  membrane  and  other  constituents  of  the  joint  are 
similar  to  those  described  in  the  general  section  (page  35). 

Symptoms  and  Physical  Signs 

It  is  very  frequently  noted  by  the  parents  or  the  patient  that  the 
symptoms  came  on  some  little  time  after  an  injury  had  been  sustained  by 
the  joint.  The  effects  of  the  injury  may  almost  imperceptibly  pass  into 
the  features  of  the  disease,  or  there  may  be  an  apparent  complete  recovery 
from  the  injury,  followed  after  a  period  by  the  signs  of  the  more  serious 
condition. 

Summary  of  Clinical  Features. — The  affection  begins  with  a  limp 
and  some  limitation  of  movement  in  the  affected  knee.  At  intervals  pain 
is  complained  of,  and  as  the  disease  progresses  the  pain  becomes  more 
constant  and  severe.  There  is  swelling  in  the  neighbourhood  of  the  joint, 
and  the  swelling  is  rendered  more  prominent  by  an  atrophy  of  the  muscles 
of  the  thigh  and  leg.  The  degree  of  movement  becomes  progressively  less, 
and  the  joint  is  distorted  into  a  position  of  flexion  with  displacement  back- 
wards of  the  leg  u])on  the  thigh.  In  the  last  stages  periarticular  abscesses 
form,  and  by  bursting  externally  constitute  sinuses.  The  infection  of  the 
underlying  bone  is  evidenced  by  osseous  thickening  and  deformity.  Such 
is  an  outline  of  the  sequence  of  the  disease ;  the  more  important  features 
may  now  be  discussed  in  detail. 

Pain. — The  pain  of  the  affection  is,  as  a  rule,  not  severe.     Its  onset  may 

17  « 


260 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


be  very  insidious  ;  for  example  a  joint  which  appears  quite  as  strong  as 
formerly,  tires  more  easily,  or  at  the  end  of  a  long  walk  or  day's  work  there 
may  be  a  distinct  limp.  Pain  is  exacerbated  by  movements  of  the  limb 
and  jars  and  by  weight-bearing.  Night-cries  are  much  less  common  than 
in  hip-joint  disease  ;  their  presence  would  indicate  considerable  advancement 
of  the  disease.  There  are  cases  in  which  pain  is  entirely  absent.  Patho- 
logically this  peculiarity  appears  to  corre- 
spond with  a  hydrops  of  the  joint,  and  the 
forcible  separation  of  the  articular  sur- 


Fi(i.  124. — The  cluaracteristie  appearaiiLie 
of  early  tuberculous  disease  of  the 
knee-joint.  There  is  slight  fle.\iou 
and  an  early  synovial  thickening. 


Fig.  125. — Tlie  deformity  of  tlexion  in 
early  knee-joint  disease.  Note  the 
antero-posterior  bulging,  the  result 
of  the  thickened  synovial  membrane. 


faces.     Local  tenderness  may  be  present  in  one  or  other  of   the  adjacent 
bones  ;  it  denotes  a  periostitis  secondary  to  an  intraosseal  focus. 

Muscular  Rigidity. — Muscular  rigidity  is  a  feature  of  this,  as  it  is  of  other 
tuberculous  joint  diseases,  but  it  is  less  prominent  than  in  the  hip-joint.  In 
the  early  stages  it  may  be  so  slight  that  its  detection  is  diflacult.  It  may 
be  evidenced  only  by  a  limitation  of  the  extreme  degrees  of  movement, 
flexion  very  often  not  being  quite  so  complete  as  it  ought  to  be.  The 
muscular  fixation  is  the  explanation  of  the  lameness  which  is  so  characteristic 
of  the  disease,  the  limp  being  the  result  of  a  fixation  of  the  hamstrings  and 
some  degree  of  persistent  flexion. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT 


261 


Deformity. — The  positions  of  deformity  arise  from  the  greater  power 
the  flexors  possess  in  contrast  to  the  extensors,  and  therefore  the  position 
is  one  of  gradually  increasing  flexion.  As  the  disease  continues  and  the 
ligaments  and  periarticular  structures  become  stretched,  the  flexion  is 
accompanied  by  an  external  rotation  of  the  tibia  upon  the  femur  and  a 
backward  displacement  of  the  leg  upon  the  thigh.  These  deformities  often 
offer  very  grave  obstacles  to  the  satisfactory  treatment  of  the  disease. 

Swelling. — The  appearance  of  the  knee  becomes  early  altered  by  an 
indistinctness  of  outline  which  is  apparent 
to  both  sight  and  touch.  In  its  begin- 
nings the  swelling  is  found  to  delimit 
with  considerable  exactness  the  distri- 
bution of  the  synovial  reflexion.  It  is 
evidenced  by  a  filling  up  of  the  natural 
hoUows  around  the  suprapatellar  liga- 
ment and  the  ligamentum  patellas  and 


Km.  126.— 'I'lic  swi-llinj;  (if  tlie  Itft  knee  is  the 
result  of  luherculous  disease  confined  to  tlie 
synovial  nienilirane.  The  ontline  of  the  swelling 
follows  the  ilistriliution  of  tlie  synovial  membrane. 


Fill.  127. — Tuliereuhnis  iliseaso  of  the 
knee-joint  with  the  aeennmlation  of 
lluiil  in  the  joint.  The  swelling  is  a 
general  distention  of  the  synovial  sac. 


a  thickening  upon  the  lateral  surface  of  the  condyles  of  the  femur 
and  the  tuberosities  of  the  tibia.  Posteriorly  the  depth  of  the  joint  from 
the  surface  generally  obscures  the  swelling,  although  it  may  be  apparent 
as  cyst-like  tumours  in  the  popliteal  space.  The  synovial  thickening  some- 
times pushes  the  patella  forwards  and  so  makes  it  appear  unusually  prominent. 
In  this  relation  Tubby  has  drawn  attention  to  an  important  detail.  When 
the  healthy  patella  is  handled  and  pushed  back  against  the  femur  there  is 
produced  the  patellar  click.  No  such  sensation  can  be  elicited  if  the  patella 
is  resting  upon  a  pad  of  thickened  synovial  membrane.     When  the  joint 


262 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


is  distended  with  fluid,  the  cUck  can  be  produced  as  long  as  the  membrane 
is  not  thickened.  This  distinction  may  constitute  an  important  point 
in  diSerential  diagnosis.  When  fluid  collects  within  the  joint,  the  swelling 
increases  in  amount,  but  its  character  alters.  It  is  now  a  general  distension 
of  the  synovial  sac,  fusiform  in  shape,  and  tapering  above  and  below. 
Secondary  to  a  focus  in  the  interior  the  outline  of  the  neighbouring  bones 
becomes  altered.  There  is  thickness  and  irregularity  from  a  reactionary 
deposit  of  new  sub-periosteal  bone.  In  the  late  stages  of  the  disease  the 
character  of  the  swelling  becomes  further  changed  by  the  development  of 
periarticular  abscesses. 

Muscular  Atrophy. — Atrophy  of  the  muscles  both  of  the  thigh  and  of  the 
calf  is  present,  and  in  acute  cases  it  reaches  a  marked  degree.  The  wasting 
gives  an  exaggerated  importance  to  the  swelling  of  the  diseased  joint. 


Fig.  128.— Ativan. 


■'[  tulierculous  disease  of  tlie  knee-joint.      Tliere  is  marked  flexion  and 
a  partial  backward  dislocation  of  the  tibia. 


Changes  in  Appearance  of  the  Joint. — In  addition  to  the  swelling,  the 
skin  over  the  joint  soon  looses  its  natural  healthy  hue.  It  becomes  pale 
and  anaemic  with  an  oedema  tons  sodden  appearance.  The  surface  veins 
stand  out  in  blue  lines,  giving  the  part  a  marbled  appearance,  and  as  the  soft 
tissue  changes  advance,  the  veins  in  the  centre  become  stretched  and  empty 
while  those  arotmd  the  periphery  increase  in  size  and  prominence.  "When 
pus  has  formed  within  the  jomt  the  skin  becomes  reddened  in  several  places. 
The  abscesses  burst  through  the  skin  and  sinuses  develop. 

Alterations  in  Length  of  the  Limb. — The  destruction  of  the  articular 
surface  and  the  rarefaction  of  the  underlying  bones  lead  in  nearly  every  case 
of  any  seriousness  to  a  diminution  in  the  length  of  the  limb.  Under  one 
condition  it  is  possible  to  imagine  an  increase  in  the  leg  measurements,  and 
that  is  a  stimulation  of  the  epiphysis  secondary  to  the  presence  of  tuberculous 
disease  either  in  the  bone  or  in  the  joint  adjacent. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT  263 

Method  and  Results  of  Examination. — A  detailed  history  of  the  illness 
and  its  symptoms  is  taken.  The  examination  opens  with  a  careful  general 
scrutiny,  enlarged  glands  are  noted,  perhaps  the  presence  of  osseous  tuber- 
culosis elsewhere.  The  general  appearance  is  observed  and  commented  on. 
Giving  detailed  attention  to  the  diseased  hmb  inspection  will  j-ield  information 
on  the  facts  of  skin  changes,  swelling,  deformity,  and  muscular  atrophy. 
Examination  by  palpation  will  add  to  the  store  of  knowledge  in  respect  of 
increased  temperature  of  the  part,  thickening  of  the  neighbouring  bones, 
enlargement  of  the  synovial  membrane,  the  mobility  or  fixation  of  the 
patella  upon  the  underlying  femur,  and  the  presence  of  fluid  in  the  joint. 
Measurements,  both  longitudinal  and  circular,  are  made.  The  longitudinal 
measurements  must  include  the  complete  length  of  the  Hmb,  as  measured 
from  the  anterior  superior  spine  or  trochanter  to  the  internal  malleolus, 
and  also  the  measurements  of  the  individual  bones  of  the  leg,  the  femur  and 
the  tibia.  The  femur  is  measured  upon  its  outer  side  from  the  top  of  the 
great  trochanter  to  the  lower  edge  of  the  external  condyle,  the  knee  being 
kept  slightly  flexed.  The  tibial  measurement  is  estimated  from  the  articular 
edge  above  the  internal  tuberosity  to  the  tip  of  the  internal  malleolus. 
Measurements  are  made  of  the  circumference  of  the  limb  in  these  localities, 
the  centre  of  the  thigh,  the  centre  of  the  calf,  and  the  diseased  joint.  For 
future  reference  any  degree  of  deformity  present  is  carefully  noted  ;  for 
example,  the  degree  of  flexion  is  recorded  by  laying  the  limb  upon  its  side 
and  outlining  on  paper  the  displacement  which  exists.  The  degree  of  move- 
ment present  in  flexion  and  extension  is  tested,  care  being  taken  to  avoid 
any  unnecessary  production  of  pain.  The  investigation  is  completed  by 
an  X-ray  examination  of  the  joint  with  its  associated  bones. 

Diagnosis 

Actual  Diagnosis. — There  is  usually  no  difficulty  in  arriving  at  the 
correct  diagnosis.  Assistance  will  be  gained  from  the  family  history  and 
perhaps  the  presence  of  tuberculous  disease  elsewhere.  The  actual  account 
of  the  onset  of  the  disease  is  usually  very  suggestive.  The  exact  diagnosis  is 
made  from  the  facts  gained  by  inspection  and  palpation  of  the  diseased  joint. 
When  fluid  is  present,  and  there  is  still  some  dubietv  as  to  the  exact  nature  of 
the  condition,  it  is  justifiable  to  withdraw  a  syringeful  of  fluid  from  the  knee 
under  strict  aseptic  precautions,  and  with  it  to  inoculate  an  animal.  A  posi- 
tive result  will  remove  all  doubt,  a  negative  result  does  not  of  necessity  mean 
that  the  condition  is  non-tuberculous.  It  is  necessary  to  mention  Yon 
Pirquet's  test  as  an  aid  in  diagnosis.  In  the  differential  diagnosis  certain 
conditions  rc([uire  to  be  excluded. 

Differential  Diagnosis. — Syphilitic  Synovitis. — Perhaps  the  condition 
most  commonly  confused  with  tuberculous  disease  is  syphilitic  synovitis. 
One  distinguishes  the  latter  by  the  bilateral  effusion  into  the  knees,  the 
ab-sence  of  pain,  and  the  small  amount  of  functional  disturliance.  Glutton 
remarks  that  he  has  never  seen  lioth  knee-joints  filled  with  fluid,  causing  uo 


264  TUBEECULOSIS  OF  THE  BONES  AND  JOINTS 

pain,  while  the  other  joints  remain  unaffected,  except  in  cases  of  hereditary 
syphiUs.  If  one  fiads  that  the  synovitis  is  associated  with  other  syphilitic 
stigmata,  and  that  it  yields  to  anti-syphilitic  treatment,  there  should  be  no 
difficulty  in  arriving  at  a  diagnosis. 

Infection  and  Gonorrhceal  Arthritis. — These  may  sometimes  be  confused 
with  a  tuberculous  condition.  If  serious  doubt  should  arise  it  may  be 
dispelled  by  the  examination  of  fluid  withdrawn  from  the  knee. 

Trauma. — Contusions  and  sprain  may  be  followed  by  pain,  tenderness, 
and  effusion,  but  under  rest  and  fixation  the  symptoms  of  acute  synovitis 
speedily  disappear. 

Rheumatism. — An  unjustifiable  confusion  sometimes  arises  between 
tuberculosis  and  rheumatism.  Rheumatism  of  a  single  joint  in  childhood 
is  practically  never  seen  without  the  positive  signs  of  fever,  heat,  sudden 
swelling,  sweating,  and  cardiac  lesions.^ 

Hwrnorrhage  into  the  Joint. — In  "  bleeders  "  an  effusion  may  occur 
into  the  joint,  and  the  synovial  membrane  acquires  an  oedematous  thickened 
appearance.  In  nearly  every  instance  the  complication  follows  a  slight 
injury,  and  the  exact  nature  is  made  clear  by  a  careful  study  of  the  general 
history. 

Arthritis  Deformans  and  Hysterical  Joints. — In  children  these  are 
sufficiently  rare  to  be  almost  negligible  in  diagnosis. 

Prognosis 

The  prognosis  depends  largely  on  early  recognition  and  efficient  treat- 
ment. If  the  case  comes  imder  appropriate  care  sufficiently  early  one  can 
usually  guarantee  a  complete  cure.  In  certain  of  these  cases  the  movement 
of  the  joint  will  be  perfect  in  every  respect ;  in  the  majority,  while  there  is 
healing  of  the  actual  disease,  the  movements  may  be  limited  through  varying 
degrees.  The  longer  the  period  before  treatment  is  undertaken  the  graver 
does  the  prognosis  become.  If  the  articular  siufaces  are  involved  cure  will 
almost  certainly  necessitate  an  ankylosis.  The  outlook  becomes  infinitely 
more  serious  when  suppuration  and  sinus  formation  appears.  Unless 
amputation  is  performed  suppuration  cases  rarely  reach  middle  life.  When 
death  occurs  it  is  due  to  prolonged  suppuration,  waxy  disease,  or  general 
tuberculosis. 

Treatment 

A.  General  Treatment. — What  has  been  said  in  regard  to  the  treat- 
ment of  hip  disease  may  be  repeated  in  speaking  of  disease  of  the  knee-joint. 
Sunshine,  fresh  air,  and  an  outdoor  life  are  invaluable,  and  as  ambulatory 
treatment  may  be  begun  early  there  is  no  reason  why  these  general  benefits 
should  not  be  fully  taken  advantage  of. 

B.  Local  Conservative  Treatment. — As  in  dealing  with  tuberculosis 

1  Willard,  Tenn.  State  Med.  Journ.,  March  1910,  p.  425. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT  265 

of  the  hip,  conservative  treatment  indicates  fixation  and  protection,  and  the 
various  methods  of  securing  these  will  now  be  enumerated. 

Welgrht  Extension. — In  early  cases,  accompanied  as  they  so  often  are 
by  flexion,  deformity,  and  considerable  pain,  it  is  well  to  begin  the  treatment 
by  fixation  and  weight  extension.  The  child  is  confined  to  bed.  The 
extension  is  applied  to  the  limb  up  to  the  knee,  and  care  is  taken  that  the 
extension  is  carried  out  in  the  proper  axis  of  the  limb,  or  in  the  line  of  any 
deformity  which  may  be  present.  When  the  position  of  the  limb  is  a  straight 
one,  sufficient  counter-extension  is  obtained  by  raising  the  foot  of  the  bed 
upon  blocks  or  pillars.  If  there  is  deformity  in  the  form  of  flexion,  the  knee 
is  supported  in  this  position  by  a  splint,  while  counter-extension  is  secured 
by  a  leather  band  which  passes  round  the  thigh  above  the  knee  and  is  con- 
nected with  weight  extension.  The  employment  of  this  treatment  for  some 
weeks  is  sufficient  to  relieve  the  pain  and  to  correct  any  early  flexion 
deformity  which  is  present.  With  the  relief  of  symptoms  one  enters  upon 
a  course  of  fixation  treatment. 

Fixation  Treatment. — Plaster  of  Paris. — Perhaps  there  is  no  material 
so  satisfactory  as  this  ;  it  provides  the  most  absolute  fixation  and  protection 
and  its  application  is  simple  and  rapid.  It  is  contra-indicated  when  the 
knee  is  flexed,  and  in  the  presence  of  abscess  or  sinus  formation.  Its  use  is 
indicated  when  the  knee  is  straight  and  deformity  is  reduced.  It  has  a 
special  value  in  children  of  tender  years  who  are  too  young  to  use  crutches. 

The  general  details  of  plaster  application  have  been  discussed  elsewhere. 
The  bandage  is  applied  from  the  upper  part  of  the  thigh  down  to  and  includ- 
ing the  foot.  If  there  is  a  suspicion  of  mobility  the  plaster  should  include  the 
hip-joint.  A  casing  extending  from  the  middle  of  the  thigh  to  the  middle 
tjf  the  leg  is  insufficient.  The  fixation  of  the  part  leads  to  muscular 
atrophy,  and  as  the  diameter  of  the  limb  diminishes  the  plaster  slips  down- 
wards until  quite  a  considerable  range  of  movement  may  be  permitted  at 
the  knee.  It  is  well  to  have  the  knee  fixed  in  a  pcsition  of  slight  flexion,  in 
case  ankylosis  should  occur  during  the  period  of  resolution,  and  to  prevent  a 
tendency  to  genu  recurvatum.  As  the  splint  frequently  breaks  behind  the 
knee  it  should  be  strengthened  in  this  situation  by  strips  of  aluminium. 
The  first  splint  is  kept  in  position  for  three  months,  at  the  end  of  that  time 
the  patient  returns  and  the  casing  is  removed.  The  joint  is  e.xamined  and 
radiographed,  and  if  the  conditions  are  favourable  a  second  splint  is  applied 
for  three  more  months.  Six  months  from  the  date  of  the  commencement  of 
treatment  may  be  considered  appropriate  for  the  commencement  of  the 
ambulatory  stage.  Diuing  the  period  of  treatment  by  plaster  it  is 
advisable  to  keep  the  patient  off  his  feet.  The  difficulty  in  ensuring  this 
is  common  knowledge,  and  if  it  is  found  impossible  to  prevent  the  patient 
from  getting  up,  he  must  be  provided  witli  a  patten  upon  the  opposite  boot 
and  a  pair  of  crutches.  Upon  no  account  should  he  be  permitted  to  bear 
weight  on  Ihc  iiffcctcd  limb. 

Ambulatory  Treatment.  —From  tiic  position  of  the  knee  it  is  possible 
in  the  sequence  of  treatment  to  ensure  fixation  of  the  part  and  yet  to  avoid 


266 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


the  deleterious  effects  which  would  arise  from  pressure  upon  the  joint. 

Certain  well-known  splints  are  employed  in  this  connection. 

Thomas  Knee  Splint. — This  consists  of  two  lateral  uprights  which  support 

the  limb  upon  either 
side,  terminating  below 
in  a  cross-bar  which 
serves  as  a  stilt,  and 
above  in  a  ring  which 
fits  the  upper  extre- 
mity of  the  thigh  and 
supports  the  body 
weight.  The  uprights 
are  made  of  round 
steel  wires  of  No.  2, 
3,  or  4  gauge.  They 
are  secured  to  the  ring 
above  and  the  bar 
below  by  brazing.  The 
ring  is  of  an  ovoid 
,  shape,  flattened  in 
front,  expanded  be- 
hind, and  wider  on  the 
are   brazed   to   it   at   a 


Fig.  129. — The  Thomas  knee  splint  viewed  antero-posteriorly. 

A.  The  posterior  view  showing  the  concave  upper  surface  of  the  riu] 

B.  Tlie  anterior  view  showing  the  straight  upper  surface. 


inner   than    on   the    outer   side.      The 


uprights 


Fig.  130. — The  Thomas  knee  splint  viewed  from  above. 

A.  The  outer  and  longei-  bar. 

B.  The  shorter  inner  bar  placed  nearer  to  the  front. 

C.  Anterior  portion  of  ring. 

D.  Posterior  portion  of  ring  upon  which  the  tuberosity  of 

the  ischium  rests. 


Fig.  131.— The  bed 
splint  variety  of 
tiie  Thomas  knee 
splint. 


lateral    and    antero-posterior    inclination — 135    and    145    degrees    respec- 
tively.     There   are    definite  reasons  for  the  irregular  shape  of  the  ring 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT 


267 


and  its  inclination.  Its  anterior  surface  is  flat  because  the  surface  of 
the  groin  is  flat ;  it  is  expanded  behind  to  fit  the  thickness  of  the 
buttock ;  the  antero  -  posterior  inclination  allows  the  ring  to  rest  with 
comfort  beneath  the  tuberosity  of  the  ischium ;  the  lateral  inclination  is 
necessitated  by  the  greater  length  of  the  outer  bar  which  rises  above  the 
level  of  the  great  trochanter.  The  ring  of  the  splint  is  made  larger  than 
the  thigh  to  permit  of  padding,  the  padding  is  thickest  on  the  posterior  and 
inner  surfaces  where  the  greatest  weight  is  borne.  To  serve  as  posterior 
supports  for  the  thigh  and  leg  a  single  or  two  separate  pieces  of  soft  leather 
are  stretched  across  the  splint  from  side  to  side.  A  strap  is  attached  to 
either  side  of  the  foot-piece,  to  provide  for  traction  in  the  limb  and  to  increase 
the  fixation  of  the  splint. 

Method  of  Adjustment. — The  limb  is  passed  through  the  ring  so  that 
the  extremity  lies  between  the  uprights 
upon  the  posterior  leather  supports. 
Adhesive  plasters  are  applied  to  eacli 
side  of  the  limb,  each  plaster  terminat- 
ing below  in  buckles.  The  splint  is 
pushed  iirmly  against  the  perineum, 
and  it  is  held  in  position  by  buckling 
the  straps  of  the  foot  cross-bar  to  the 
ends  of  the  extension  tapes.  By 
means  of  these  straps  as  much  exten- 
sion is  carried  out  as  may  be  neces- 
sary. The  splint  is  further  secured  by 
turns  of  a  bandage  around  the  knee, 
and  sometimes  above  the  ankle.  Many 
splints  are  fitted  with  a  shoulder  strap, 
which,  fastened  to  the  ring  in  front 
and  behind,  passes  over  the  opposite 
shoulder.  The  sole  of  the  boot  upon 
the  healthy  limb  is  raised,  and  the 
patient  uses  crutches.  In  this  variety 
of  splint  the  foot  is  entirely  off  the 
ground,  and  as  the  joint  continues  to 
improve  a  further  stage  in  the  treatment  may  be  reached  by  the  employ- 
ment of  the  Calliper  splint. 

The  Calliper  Splint. — This  splint  possesses  the  advantage  that  instead 
of  walking  upon  a  stilt  ring  the  patient  walks  on  the  sole  of  the  boot.  The 
splint  differs  from  the  Thomas  splint  at  its  lower  end.  In  the  Calliper  splint 
the  two  lateral  bars  are  cut  off  at  their  lower  end  and  turned  inwards  at  a 
right  angle.  Tliey  are  inserted  into  a  steel  tube  wliich  pas.scs  tlirough  the 
heel  of  the  boot.  The  lateral  bars  are  made  slightly  longer  than  the  leg, 
so  that  the  patient's  heel  is  lifted  nearly  an  inch  from  the  inside  of  the  sole 
when  walking.  Tlie  jar  of  impact  with  the  ground  is  thus  diminished. 
When  the  heel  strikes  against  the  back  of  the  boot  it  sometimes  excoriates, 


Fig.  1S2. — Tlionias  knee  splint  applied. 
There  is  a  patten  fastcneil  to  the  sole 
of  the  boot  of  the  opposite  sic-lc. 


268 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


in  which  case  a  triangular  piece  of  leather  should  be  put  in  the  back  of  the 
shoe  for  the  heel  to  play  on,  and  it  is  sometimes  necessary  to  slit  the  back 
seam  just  above  the  counter  for  a  short  distance.  The  limb  may  be  kept  in 
position  by  a  knee-cap  or  by  wide  thigh  and  calf  leather  lacings.  The  splint 
is  kept  in  position  until  sufficient  time  has  elapsed  for  a  natural  cure.  If 
there  have  been  no  active  symptoms  of  disease  for  several  months,  the  splint 
is  tentatively  removed  at  night  and  worn  during  the  day.  Later  the  splint 
is  removed  entirely,  or  a  light  supporting  brace  jointed  at  the  knee  is  worn. 
Sitmmary  of  Conservative  Treatment. — When  the  case  is  first  seen,  if 
there  is  anything  about  it  of  the  nature  of  the  acute  in  the  shape  of  pain 

and  flexion  deformity,  the  joint  is  treated  by  fixation  with 

weight  extension.     A  very  few  weeks  of  this  treatment 

is    sufficient    to     relieve    the  

symptoms  to  such  an  extent 

that    it   becomes    possible   to 

enter  upon  the  second  stage  of 

treatment,    namely    complete 

fixation  by  means  of  a  plaster 

of  Paris  case.     During  a  period 

of   six  months    two    separate 

cases  are   applied.      With  the 

conclusion  of  the  treatment  by 

plaster,  the  ambulatory  stage 

is  entered  on,  and   to   secure 

fixation  during  this  period  a 

Thomas    knee    splint    is ,  the 

most    suitable    apparatus    to 

employ.      The    period  during 

which  it  will  be  necessary  to 

continue    wearing     the    knee 

splint  varies  according  to  the 

clinical   condition  of  the  dis- 
eased    joint.      Certainly    the 

splint  must  be  worn  until  all 

traces  of  the  disease  have  dis- 
concluding  stages  of  the  treatment  are  carried  out  with  a 
Such  is  the  routine  which  one  attempts  to  follow  in  actual 


Fig.  133.— The  Cal- 
liper splint.  The 
turned  -  in  lower 
ends  are  inserted 
into  a  tunnel  pass- 
ing through  the 
heel  of  the  boot. 


Fig.  134.- 


-Thonias  knee  splint 
in  use. 


appeared.     The 
CalHper  splint, 
practice. 

In  addition  to  the  treatment  of  fixation  and  protection  which  has  been 
described,  there  are  various  local  measm'es  which  can  be  adopted,  and  which 
have  been  already  described  in  the  general  section  upon  the  treatment  of 
tuberculous  joints  (page  103).  Among  the  methods  which  may  be  mentioned 
are  the  injection  of  a  sterile  emulsion  of  iodoform  in  glycerin  (10  per 
cent)  into  the  joint  cavity  in  amounts  of  5  to  10  cc.  at  intervals  of 
three  to  four  weeks.  Bier's  congestive  treatment,  the  application  of  allyl 
sulphide  ointment,  and  counter  irritation  of  the  skin  by  means  of  a  cautery. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT  269 

Lannelongue's  Sclerog-enic  Injections.  —  The  natural  cure  of 
tuberculous  disease  is  by  the  imprisoning  of  the  focus  in  a  capsule  of  dense 
fibrous  tissue.  Lannelongue  has  attempted  to  forestall  or  at  least  to  stimu- 
late nature  by  injecting  into  a  joint  an  irritant  which  will  induce  the  forma- 
tion of  scar  tissue,  and  thus  indirectly  overcome  the  disease.  The  method 
is  as  follows  :  A  10  per  cent  solution  of  chloride  of  zinc  is  prepared,  and 
with  a  fine  hypodermic  needle  from  8  to  10  minims  of  the  solution  are  in- 
jected at  various  points  around  the  diseased  area.  The  injections  are  made 
into  healthy  tissue  immediately  adjoining  the  disease.  Excellent  results 
have  been  obtained  by  this  method. 

The  Correction  of  Deformity. — The  deformities  which  may  exist 
are  those  of  flexion,  external  rotation,  and  backward  displacement  of  the 
tibia  upon  the  femur.  The  causes  of  each  are  different.  The  flexion 
deformity  is  in  its  early  stages  the  result  of  a  reflex  contraction  of  the  ham- 
strings, and  later  of  an  actual  structural  shortening  and  contracture.  Ex- 
ternal rotation  is  mainly  due  to  an  exaggerated  action  of  the  biceps.  The 
backward  displacement  is  an  indication  that  the  ligaments,  more  especially 
the  crucial,  have  become  infected,  softened,  and  stretched.  The  weight  of 
the  limb  with  the  contracting  posterior  muscles  is  responsible  for  the 
commencing  backward  dislocation.  Considering,  therefore,  the  various 
etiologies  the  treatment  of  the  different  deformities  must  vary. 

Correction  by  Traction. — As  muscular  contraction  is  the  earliest  cause 
of  flexion  deformity  it  may  be  corrected  by  simple  weight  traction.  The 
leg  must  be  supported  so  that  no  direct  leverage  is  exerted  upon  the  seat  of 
the  disease  (see  page  101). 

Correction  by  Plaster  Bandage. — The  plaster  bandage  has  much  the  same 
action  as  weight  extension  in  reducing  deformity  when  the  deformity  is 
the  result  of  simple  muscular  contraction.  A  close-fitting  plaster  bandage 
is  applied  from  the  groin  down  to  and  including  the  foot ;  no  attempt  is 
made  in  any  way  to  correct  the  deformity.  At  the  end  of  a  week  the  plaster 
is  removed,  when  it  will  be  found  that  the  muscular  spasm  has  diminished, 
and  the  deformity  may  now  be  considerably  reduced.  In  persistent  cases 
several  applications  of  the  bandage  may  be  necessary. 

Immediate  Reduction  under  Anceslkesia  and  the  Application  of  the  Plaster 
Bandage. — Under  anaesthesia  the  more  resistent  deformities  may  be  reduced 
by  traction  and  leverage.  When  the  deformity  is  corrected  a  plaster  case 
is  applied  to  keep  the  limb  in  position.  This  method  has  the  advantage  of 
speed  to  recommend  it.  It  is  advised  to  break  down  adhesions  by  flexing 
the  limb,  and  then  by  forcible  extension  to  straigliten  it.  There  are  certain 
drawbacks,  however.  In  reducing  the  deformity  care  must  be  taken  to  avoid 
using  too  much  force.  Tlie  epiphysis  of  children  becomes  rarefied  in  tuber- 
culous disease  and  easily  displaced.  Further,  the  deformity  has  a  strong 
tendency  to  recur  when  treated  by  such  an  immediate  reduction. 

Reduction  bg  the  Billroth  Splint.  -In  obstinate  cases  the  Billrotli  splint  as 
modified  by  iStiliman  may  be  employed.  The  prominences  of  the  lower 
limb  are  well  and  carefully  padded,  especially  over  the  outer  surface  of  the 


270  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

condyles  of  the  femur,  and  the  popliteal  region  over  the  upper  border  of  the 
tibia.  A  plaster  bandage  is  applied  from  the  groin  to  the  toes,  being  made 
especially  strong  in  the  popliteal  region,  and  in  the  plaster  on  either  side  of 
the  knee  there  are  incorporated  expanded  tin  splints  to  which  curved  and 
slotted  steel  bars  are  attached.  When  the  bandage  has  hardened,  it  is  divided 
into  two  parts  by  a  circular  cut  above  the  knee,  and  the  slotted  spUnts  being 
connected,  the  bolts  in  the  slots  are  adjusted  in  such  a  way  as  to  form  a 
hinged  splint,  the  centre  of  movement  being  slightly  above  and  in  front  of 
the  knee  joint.  If  the  limb  be  extended  slightly  the  action  of  the  lateral 
hinges  is  such  as  gradually  to  force  the  tibia  away  from  the  femur.  This 
opens  up  the  posterior  part  of  the  circular  incision,  and  the  part  is  held  open 
by  the  insertion  of  a  cork  wedge.  From  day  to  day  larger  wedges  are 
introduced,  and  the  deformity  gradually  corrected  until  the  limb  is  straight. 
When  the  correction  is  complete  a  new  plaster  bandage  is  applied  and  kept 
in  position  for  some  weeks. 

Correction  by  the  Thomas  Knee  Splint. — The  Thomas  splint  may  be  used 
as  a  corrective  of  deformity  in  two  ways.  By  employing  simple  traction  it 
overcomes  the  flexion  deformity  which  is  the  result  of  simple  muscular 
contraction.  At  a  later  period,  when  there  may  be  true  contracture  and 
shortening,  the  splint  can  be  made  to  exert  a  correcting  action  by  forcing 
the  knee  towards  the  splint  with  the  aid  of  a  firmly  appUed  elastic  or  domette 
bandage  ;   as  the  bandage  slackens  it  is  reapplied. 

Forcible  Correction  by  the  Genuclast. — Certain  mechanical  devices  or 
genuclasts  have  been  employed  to  correct  long  standing  deformities,  more 
especially  when  the  displacements  are  associated  with  a  subluxation  back- 
wards of  the  tibia.  Lateral  steel  bars,  attached  below  to  a  handle  in  a 
catapult  shape,  are  placed  upon  each  side  of  the  leg.  Pressure  can  be  exerted 
posteriorly  over  the  head  of  the  tibia  by  a  plate  attached  indirectly  to  the 
lateral  bars  and  furnished  with  an  adjustable  screw.  Counter  extension 
is  exerted  over  the  lower  end  of  the  femur  and  the  lower  end  of  the  tibia  by 
means  of  strong  linen  bands.  Pressure  forward  on  the  head  of  the  tibia 
is  exerted  by  turning  the  screw  handle.  The  calf  muscles  protect  the 
artery  and  nerve  from  injurious  pressure,  and  gradually  the  deformity  is 
overcome.  The  instrument  is  one  of  considerable  power  and  care  must  be 
used  in  its  manipulation. 

Correction  by  Operation. — When  bone  ankylosis  is  present  the  flexion 
deformity  is  overcome  by  operation.  Operative  measures  consist  in  a  linear 
osteotomy  or  the  removal  of  a  wedge  of  bone — a  cuneiform  osteotomy. 
In  children  a  linear  osteotomy  of  the  femur  is  to  be  preferred,  as  it  does 
not  in  any  way  interfere  with  the  growing  parts  of  the  bone,  and  yet 
answers  well  iu  straightening  the  limb. 

Linear  Osteotomy. — On  either  the  inner  or  the  outer  side  of  the  rectus 
tendon  a  longitudinal  incision  is  made,  the  centre  of  the  incision  being  a 
finger-breadth  above  the  upper  portion  of  the  external  condyle.  A 
MacEwan's  osteotome  is  inserted  into  the  incision  and  the  bone  divided. 
It  may  be  found  that  contraction  of  the  hamstrings  renders  correction 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT  271 

impossible.  Should  this  be  so,  one  must  have  no  hesitation  in  di\'iding  the 
shortened  muscles.  It  sometimes  happens  that  di\'ision  of  the  femur  is 
insufficient ;  the  tibia  is  then  divided  below  the  anterior  tubercle.  J.  W. 
Perkins  recommends  an  osteotomy  carried  out  some  distance  above  the 
joint,  and  in  support  of  his  recommendation  he  quotes  the  following  argu- 
ments : 

(f/)  There  is  entire  avoidance  of  injury  to  the  epiphyseal  line. 

(6)  There  is  avoidance  of  injury  to  or  undue  stretching  of  the  great 
vessels  and  nerves  of  the  popliteal  space. 

As  the  operation  includes  the  removal  from  the  femur  of  a  rhomboid  of 
bone  there  is  a  considerable  amount  of  shortening.  The  operation  has 
nothing  to  recommend  it  over  linear  osteotomy. 

Cuneiform  Osteotomy  of  the  Anhjlosed  Knee. — It  is  presumed  that  the 
femur,  tibia,  and  patella  are  fused  into  one  bony  mass.  The  front  of  the 
knee  is  exposed  by  a  large  U-shaped  flap  having  its  base  directed  upwards. 
With  a  saw  or  a  very  broad  chisel  a  segment  of  bone  is  excised.  The  upper 
cut  through  the  bone  should  be  nearly  at  a  right  angle  to  the  axis  of  the 
femur,  the  lower  cut  nearly  at  a  right  angle  to  the  axis  of  the  tibia.  It  is 
not  advisable  to  carry  the  apex  of  the  wedge  as  far  back  as  the  ligaments 
of  the  joint,  by  doing  so  there  is  a  danger  of  wounding  the  popliteal  artery, 
and  when  the  deformity  is  corrected  an  awkward  projection  remains  at  the 
posterior  part.  The  wedge  should  therefore  be  planned  so  that  the  apex 
lies  about  half  an  inch  in  front  of  the  posterior  bony  surface.  The  wedge 
is  removed  and  the  remaining  bridge  of  bone  broken  down  by  firm  flexion 
of  the  knee.  If  the  remaining  bone  offers  a  reduction  to  proper  apposition 
it  should  be  chiselled  carefully  away.  By  this  procedure  all  chance  of 
injuring  the  popliteal  artery  is  avoided.  The  osseous  surfaces  may  be 
approximated  by  means  of  nails  inserted  obliquely  through  the  head  of  the 
tibia  into  the  femur  (see  later,  p.  274).  The  limb  is  fastened  on  a  posterior 
splint. 

Treatment  of  Abscesses  and  Sinuses. — The  treatment  of  abscessesand 
sinuses  is  similar  to  that  recommended  in  disease  of  the  hip-joint.  Abscesses 
are  generally  superficial  and  are  easily  recognised  and  treated.  The  sinuses 
are  usually  short  and  direct ;  they  do  not  dissect  tortuously  among  muscles 
as  hip  sinuses  so  often  do. 

Operative  Treatment  of  Knee-joint  Disease 

Operations  for  Tuberculous  Disease  of  the  Knee-joint. — The 

operative  measures  which  may  be  called  for  are  those  of  excision,  syno- 
vectomy, and  amputation. 

Excision. — E.xcision  necessarily  means  the  removal  of  tiie  entire 
synovial  surface,  the  ablatiot\  of  the  articular  ends  of  the  bones,  and  the 
exposure  of  healthy  bone  surfaces  beneath.  A  successful  and  complete 
operation  is  almost  necessarily  followed  by  an  ankylosod  joint. 

Indications. — The  operation  is  indicated  in  cases  in  wiiicli  conservative 


272 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


treatment  has  failed  to  arrest  the  disease,  iii  which  originally  the  disease  is 
too  extensive  to  render  conservative  treatment  justifiable,  or  in  which  the 
general  health  is  beginnmg  to  fail.  It  is  said  that  the  operation  should  not 
be  performed  in  young  children,  because  of  necessity  it  interferes  with  the 
epiphyseal  cartilages,  and  therefore  with  the  growth  of  the  limb.  It  should 
rather,  perhaps,  be  stated  that  in  young  children,  if  there  is  a  likelihood  of 
operation  becoming  necessary,  such  ought  not  to  be  delayed  too  long.  It 
ought  to  be  performed  at  such  a  period  that  the  articular  surfaces  may  be 
removed  without  interfering  with  the  epiphyseal  cartilages.  Any  method 
of  exposing  the  joint  is  good  if  it  fulfils  the  following  requirements  :  free 
access  to  the  joint,  the  easy  removal  of  all  diseased  tissues,  with  the  minimum 
destruction  of  healthy  structures,  the  possession  after  operation  of  a  strong, 
useful  limb  with  an  ankylosed  knee,  and  as  little  shortening  as  possible. 


Fig.  135. — Miller's  incision 
for  excision  of  the  knee-joint. 


Fig.  136. — Te.\tor's  incision 
for  excision  of  the  knee-joint. 


Fig.  137. — Kocher's  incision 
for  excision  of  the  knee-joint. 


Incisions. — A  large  number  of  incisions  have  been  planned  to  expose 
the  joint.  Volkmann  recommends  a  transverse  incision  passing  across  the 
front  of  the  joint  from  condyle  to  condyle  over  the  centre  of  the  patella. 
The  patella  is  divided  to  expose  the  interior  of  the  joint.  Miller  advocated 
a  similar  incision,  his  operation  including  not  a  division  but  a  complete 
removal  of  the  patella.  Diakonow  uses  an  incision  which  passes  vertically 
over  the  centre  of  the  joint.  He  splits  the  patella  from  above  downwards 
in  the  middle,  and  separates  the  insertion  of  the  patellar  ligament  from  each 
side  together  with  a  scale  of  cartilage  or  bone.  An  excellent  manner  of 
exposing  the  joint  is  by  a  transverse  curved  incision,  convex  downwards 
as  far  as  the  tubercle  of  the  tibia,  the  horns  of  the  incision  being  over  the 
condyles  and  opposite  the  centre  of  the  patella.  With  this  incision  Textor's 
name  is  associated.  Cheyne  and  Burghard  recommend  an  H -shaped  incision. 
The  vertical  incisions  should  reach  from  the  upper  limit  of  the  suprapatellar 
pouch  well  on  to  the  anterior  surface  of  the  tibia,  and  should  be  from  1  inch 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT  273 

to  1|  inches  away  from  the  edges  of  the  patella.^  The  verticals  are  united 
by  a  transverse  incision  passing  over  the  centre  of  the  patella.  Kocher  ^ 
formerly  advocated  a  Textor's  curved  incision,  but  he  has  now  replaced  it 
by  an  external  J -shaped  one.  The  incision  which  begins  over  the  vastus 
extermis,  a  hand-breadth  above  the  upper  border  of  the  patella,  extends 
at  first  vertically  downwards  a  finger-breadth  external  to  it,  and  then  curves 
slightly  inwards  to  end  at  the  anterior  border  of  the  tibia  just  below  its 
tuberosity.  Kocher  claims  for  this  incision  an  excellent  access  to  the  joint 
and  a  minimum  of  disturbance  in  the  strength  of  the  part. 

Openition. — Beyond  the  differences  in  the  origmal  incision,  the  stages 
of  the  operation  are  practically  the  same  in  each  instance.  Many  operators 
recommend  the  use  of  a  tourniquet,  but  while  this  has  the  advantage  of 
rendering  the  operation  field  clear,  it  is  apt  to  be  followed  after  operation 
by  a  most  troublesome  and  persistent  oozing. 

As  a  standard  the  operation  will  be  described  as  it  is  carried  out  with 
a  curved  Textor  incision.  The  incision  is  carried  down  to  the  deep  fascia 
all  round,  and  the  large  U-shaped  flap  so  outhned  is  raised  carrying  with  it 
the  patella.  To  permit  of  raising  the  patella  its  ligament  must  be  divided 
about  the  centre,  or  the  insertion  of  the  ligament  must  be  chiselled  off  with 
the  tubercle  of  the  tibia. 

When  the  patellar  flap  is  thus  raised  the  capsule  of  the  joint  is  opened 
on  each  side  as  far  as  the  posterior  limit  of  the  incision.  The  knee  is  bent 
and  the  interior  of  the  joint  partly  exposed  to  view.  It  may  not  be  necessary 
to  divide  either  the  internal  or  the  external  lateral  ligaments,  but  in  the 
event  of  such  a  step  becoming  essential  the  ligaments  are  separated  sub- 
periosteally  from  their  attachments  to  the  femoral  condyles. 

With  the  joint  fully  flexed  the  crucial  ligaments  are  brought  into  view, 
and  they  are  divided  about  their  centre.  A  careful  survey  is  now  made  of 
the  Ulterior  of  the  joint,  and  the  exact  extent  of  the  disease  ascertained. 
Having  satisfied  one's  self  on  this  point,  the  removal  of  the  synovial  membrane 
is  proceeded  with.  A  knife  and  scissors  are  conveniently  used  in  the  dissec- 
tion. The  separation  is  begun  in  front  and  carried  deeper.  In  front  and 
below,  the  infrapatellar  pad  of  fat  and  its  synovial  membrane  are  removed. 
In  front  and  above,  the  synovial  membrane  is  dissected  away  from  either  side 
of  and  above  the  patella,  and  from  the  suprapatellar  and  sub-crural  pouches. 

Laterally  the  membrane  is  dissected  off  the  surfaces  of  the  femoral 
condyles  and  the  tuberosities  of  the  tibia,  especially  from  the  internal  tuber- 
osity of  the  tibia,  where  there  is  a  distinct  sacculation  from  the  main  synovial 
cavity.  Before  the  synovial  tissue  can  be  satisfactorily  removed  from  the 
posterior  part  of  the  joint  more  room  must  be  obtained.  The  crucial  liga- 
ments are  carefully  dissected  from  their  attachment  to  the  inter-condyloid 
notch  of  the  femur.  The  semi-lunar  cartilages  may  be  removed  from  the  iiead 
of  the  tibia,  or  they  may  be  kept  in  position  to  be  taken  away  later  wit  li  the 
articular  cartilage. 

'  Cheyno  and  lJurglmid,  Manual  of  Surgical  Treatment,  Part  iv.  p.  209. 
^  Kochor,  Text-book  of  Operative  Surgery,  translated  by  Stiloa,  ]>.  201. 

18 


274  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

Each  articular  surface  is  removed  with  a  saw.  The  amount  must  be 
sufficient  to  include  the  whole  disease-bearing  area.  The  bone  is  divided 
in  a  plane  parallel  to  the  articular  surface.  It  may  be  sawn  in  such  a  way 
as  to  leave  opposing  flat  surfaces,  or  by  using  a  strong  fret  saw  the  raw 
surfaces  may  be  so  shaped  as  to  fit  one  another  with  less  liability  to  displace- 
ment. The  lower  end  of  the  femur  is  left  slightly  convex,  and  the  upper 
end  of  the  tibia  is  sawn  somewhat  concave  in  order  to  receive  the  lower  end 
of  the  femur.  In  dividing  the  bone  it  is  an  advantage  to  slip  over  and  behind 
the  articular  surface  a  sterilised  triangular  handkerchief  or  bandage  ;  by  it 
one  has  more  control  over  the  end  of  the  bone,  and  it  is  possible  to  pull  the 
bone  well  forward,  and  so  to  avoid  the  risk  of  injuring  the  posterior  structures. 
There  may  be  such  extensive  disease  of  the  underlying  bone  that  the  removal 
of  the  articular  surface  is  insufficient.  Isolated  foci  are  scraped  out  with  a 
sharp  spoon,  and  the  interior  of  the  cavity  curetted.  If  the  disease  is  suffi- 
ciently extensive  to  involve  an  entire  condyle  or  tuberosity.  Stiles  ^  recom- 
mends that  the  affected  condyle  or  tuberosity  be  sawn  through  beyond  the 
seat  of  the  disease  at  a  deeper  level  than  its  fellow.  The  opposite  bone  is 
dealt  with  in  a  similar  but  converse  manner.  The  result  of  this  manoeuvre 
is  to  produce  two  Z-shaped  sawn  sm'faces  which  must  be  so  fashioned  that 
when  the  limb  is  brought  into  good  position  they  dovetail  accurately  the 
one  into  the  other.  In  other  cases  an  oblique  section  is  made  from  before 
backwards,  or  from  side  to  side  according  to  the  position  of  the  focus.  The 
slice  of  bone  removed  is  thus  wedge-shaped,  with  the  disease  towards  the 
base  of  the  wedge.  The  extremity  of  the  opposing  bone  is  also  sawn  obliquely, 
and  care  must  be  taken  that  the  surface  which  is  left  is  in  a  plane  exactly 
parallel  to  the  first.  When  it  has  been  necessary  to  saw  the  bones  obliquely, 
they  should  be  nailed  into  position  to  prevent  the  risk  of  a  gliding  movement 
between  the  two  surfaces.  If  the  patella  is  to  be  left,  its  articular  surface 
is  removed,  and  a  corresponding  flat  surface  is  made  for  its  reception  upon 
the  outer  part  of  the  trochlear  surface  of  the  femur. 

With  the  removal  of  the  articular  surfaces  free  access  can  be  obtained 
to  the  back  of  the  joint,  and  the  synovial  membrane  from  this  part  is  care- 
fully dissected  away.  Tuberculous  debris  lying  around  the  tendon  of  the 
popliteus  muscle  is  hable  to  be  overlooked,  the  tendon  therefore  ought  to 
be  exposed  and  examined.  Bleeding  is  carefully  arrested,  as  it  is  most 
essential  to  be  able  to  close  the  wound  without  drainage.  The  limb  is  put 
into  proper  position,  and  the  osseous  surfaces  being  brought  together  it  is  seen 
whether  the  line  of  section  has  been  properly  made  or  not.  If  there  is  any 
unusual  divergence  a  correcting  scale  of  bone  must  be  removed.  To  secure 
good  approximation  of  the  bones  until  fixation  has  become  firm.  Stiles  recom- 
mends that  the  opposed  surfaces  be  fixed  by  long  steel  nails  which  are  driven 
one  on  each  side  upwards  through  the  head  of  the  tibia  into  the  femur. 
They  are  left  in  position  for  about  three  weeks.  At  the  end  of  that  time  they 
are  easily  taken  out,  and  there  is  sufficient  union  of  the  opposed  surfaces 
to  prevent  a  deformity  occurring.  In  closing  the  wound,  if  the  patella  has 
'  Stiles,  Oper.  Surg.  (Burghard),  vol.  ii.  p.  99. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT 


275 


not  been  removed,  the  divided  ligamentum  patellae  is  reunited,  or  the 
separated  tuberosity  is  stitched  back  to  the  tibia.  The  remains  of  the 
capsule  are  brought  together  with  interrupted  catgut  sutures,  also  the  opening 
above  the  knee  in  the  vastus  externus.  The  skin  wound  is  closed  with 
sutures  of  silkworm  gut  or  with  Michel's  clips. 

After  Treatment. — After  the  operation  it  is  sometimes  an  advantage 
to  secure  the  limb  in  a  vertical  excision  splint  (Fig.  138).  This  is  a  modifica- 
tion of  Liston's  long  splint,  in  which  a  short  vertical  bar  is  attached  opposite 
the  hip-joint,  extending  upwards  for  a  slightly  greater  length  than  the  limb. 
The  limb  is  flexed  at  the  hip  to  a  right  angle  and  bandaged  to  the  vertical. 
This  splint  has  the  advantages  of  minimising  bleeding  and  of  lessening  the 
liability  of  post-operative 
displacement  of  the  ex- 
cised surfaces.  It  has 
one  disadvantage  —  its 
use  seems  to  cause  a 
considerable  degree  of 
pain,  probably  by  the 
continual  apposition 
under  pressure  of  the 
two  raw  surfaces.  It  is 
sufficient  to  keep  the 
limb  in  the  vertical 
splint  for  forty  -  eight 
hours.  At  the  end  of 
that  period  the  limb  is 
brought  straight  and 
secured  to  a  lateral  splint 
with  a  piece  passing  behind  to  support  the  parts.  Stiles  recommends  the 
use  of  a  MacEwan's  knock-knee  splint  for  this  piu'pose. 

AVhen  the  wound  is  firmly  healed  the  limb  is  fitted  with  a  plaster  case 
extending  from  groin  to  ankle.  The  case  is  kept  on  with  interval  changes 
for  six  months.  At  the  end  of  that  period  the  patient  is  allowed  to  go  about 
with  crutches,  and  finally  to  bear  full  weight  upon  the  limb. 

Synovectomy. — For  this  operation  the  terms  synovectomy,  erasion, 
and  artlirectoiiiy  have  been  employed.  The  word  arthrectomy  ought  to  be 
applied  to  a  true  excision,  synovectomy  essentially  means  a  removal  of  ail 
the  disease-bearing  synovial  membrane.  Should  it  become  necessary  to 
carry  synovectomy  further,  and  to  gouge  out  diseased  foci  from  the  under- 
lying bones,  no  special  name  should  be  applied  to  the  procedure,  as  it  partakes 
of  the  nature  of  both  synovectomy  and  excision. 

G.  A.  Wright,^  who  first  advocated  the  operation,  recommended  it  in 
children  in  preference  to  excision,  because  he  claimed  that  it  was  accompanied 
by  a  less  degree  of  shortening,  and  that  its  performance  was  less  likely  to 
be  followed  by  ankylosis.     The  advocate  is  correct  when  he  claimed  that 

»  Lancet,  1881,  vol.  ii.  p.  992. 

18  « 


Fig.  138. 


-The  vertical  e.'ccision  splint  used  after  exci.sioii 
of  tlie  knee-joint. 


276  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

the  operation  is  associated  with  a  minor  degree  of  shortening.  That  it  is 
likely  to  be  followed  by  a  movable  joint  is  a  false  hope  ;  a  satisfactory  and 
therefore  necessarily  a  complete  operation  is  almost  certain  to  be  followed 
by  some  degree  of  ankylosis. 

^Vhat  one  might  designate  as  a  case  typically  suitable  for  this  operation, 
would  be  one  in  which  the  disease  was  entirely  limited  to  the  synovial 
membrane,  and  more  especially  to  a  localised  area  at  the  front  of  the  joint, 
in  which  the  articular  cartilage  and  underlying  bones  were  intact  and  in 
which  there  were  no  sinuses  or  abscesses.  When  these  facts  are  all  taken 
into  consideration  it  would  appear  that  there  are  really  very  few  conditions 
under  which  the  operation  would  be  called  for.  A  case  sufficiently  early 
to  be  suitable  would  probably  do  equally  well  under  a  conservative  regime. 
When  the  operation  is  performed  it  has  such  a  tendency  to  be  followed  by 
a  fibrous  ankylosis  that  one  is  better  advised  to  carry  the  procedure  further, 
and  by  removing  the  articular  surfaces  perform  an  excision,  and  so  give  the 
child  a  stiff  but  at  least  a  strong  limb. 

In  performing  the  operation  the  joint  is  opened  by  one  of  the  incisions 
described  under  excision.  A  Volkmann's  straight  transverse  or  a  Textor's 
ciu-ved  transverse  are  excellent.  With  forceps,  knife,  and  scissors  curved 
on  the  flat,  a  free  removal  is  made  of  the  synovial  membrane.  To  obtain 
complete  exposure  it  will  be  necessary  to  divide  the  crucial  ligaments.  The 
membrane  is  dissected  away  from  the  popliteal  surface  with  great  care.  If  it 
is  possible  the  divided  crucial  ligaments  are  reunited  with  catgut  sutures. 
The  wound  is  closed  without  drainage. 

The  after  treatment  of  the  case  is  at  first  similar  to  that  of  excision. 
If  an  attempt  is  to  be  made  to  secure  a  movable  joint,  massage  and  exercises 
must  be  begun  within  a  reasonable  time,  at  least  within  three  weeks  after 
the  operation. 

The  Results  of  Excision  of  the  Knee. — Mr.  Stiles  ^  reports  in  his 
paper  that  during  the  past  ten  years  63  excisions  of  the  knee  have  been 
performed,  and  30  of  these  cases  have  been  traced.  In  regard  to  the  immediate 
post-operative  results  there  was  healing  by  first  intention  iii  53  cases,  while 
in  9  cases  the  wound  broke  down  or  recurrence  set  in  within  one  month  after 
operation.  Of  the  30  cases  which  had  been  traced  and  examined,  and 
which,  therefore,  might  be  considered  as  constituting  examples  of  the  late 
results  of  operation,  it  was  found  that  in  29  instances  there  was  complete 
bony  ankylosis,  and  in  1  a  slight  degree  of  movement.  The  position  in 
27  cases  was  one  of  slight  flexion,  it  averaged  10  degrees.  In  one  instance 
the  leg  was  perfectly  straight,  and  in  2  there  was  a  tendency  to  genu  recur- 
vatum.     Three  cases  showed  a  slight  degree  of  genu  valgum. 

Considering  the  question  of  shortening,  in  one  case  there  was  no  differ- 
ence in  length  between  the  limbs,  and  it  would  appear  that  the  operation 
had  stimulated  the  growth  of  the  neighbouring  epiphyses.  In  nine  cases 
the  shortening  amounted  to  less  than  1  inch,  in  twelve  to  between  1  and  2 
inches,  in  three  it  reached  3  to  4  inches,  and  in  two  it  amounted  to  5^  inches. 
1  StUes,  Brit.  Med.  Jour.,  Nov.  16,  1912. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT  277 

In  those  instances  in  whicii  the  amount  of  shortening  exceeded  3  inches, 
a  secondary  cuneiform  resection  had  been  performed,  and  therefore  these 
cases  cannot  be  considered  as  true  instances  of  excision.  In  regard  to  the 
amount  of  inconvenience  produced  by  the  greater  degrees  of  shortening, 
Mr.  Stiles  says  that  the  patient  experiences  little  or  no  inconvenience 
from  an  amount  of  shortening  which  does  not  exceed  2  inches. 

Amputation  was  subsequently  performed  in  twelve  cases.  One  month 
after  operation  there  was  a  total  mortality  of  4 — one  from  tuberculous 
meningitis,  two  from  general  tuberculosis,  and  one  from  measles. 

Operations  for  para-articular  Tuberculosis.  —  Original  deposits 
of  tubercle  in  the  epiphyseal  or  metaphyseal  regions  at  the  lower  end  of  the 
femur  or  the  upper  end  of  the  tibia  are  usually  early  associated  with  invasion 
of  the  joint.  It  is,  however,  possible  for  the  disease  to  be  for  a  short  time 
confined  to  the  bone,  and  in  such  cases  it  is  advisable  to  remove  the  diseased 
focus  by  an  extra-articular  route  in  order  to  eliminate  the  possibility  of  a 
later  joint  infection.  The  position  of  the  disease  is  accurately  localised 
by  X-ray  examination,  preferably  by  a  stereoscopic  photograph.  The  lesion 
is  exposed  and  thoroughly  evacuated.  The  operation  is  eminently  satis- 
factory, if  by  it  one  is  able  to  prevent  a  later  infection  of  the  joint  cavity. 

Amputation. — With  our  improved  knowledge  of  treatment  by  general 
means,  and  the  advances  which  have  been  made  in  conservative  and  operative 
technique,  the  necessity  for  amputation  has  greatly  diminished. 

Indications. — This  dernier  ressort  is  called  for  in  those  cases  in  which 
local  attempts  at  removal  of  the  disease  have  failed,  in  which  the  part  is 
riddled  with  abscesses  and  sinuses,  in  which  there  is  a  diffuse  osteomyelitis 
extending  from  the  joint  along  the  bones,  and  in  which  the  general  health 
of  the  patient  is  beginning  to  be  seriously  affected.  Further  it  is  to  be 
recommended  in  early  childhood  when  the  epiphyseal  cartilage  is  extensively 
diseased,  and  natural  cure  would  necessarily  be  associated  with  great  shorten- 
ing and  a  useless  limb.  The  amputation  practised  is  usually  one  through 
the  middle  of  the  thigh.  The  danger  must  be  avoided  of  attempting  to  secure 
a  long  stump  at  the  risk  of  recurrence  of  the  disease. 

Arthroplastry. — An  ankylosed  knee  is  by  no  means  a  severe  handicap, 
provided  that  the  ankylosis  is  sufficiently  rigid.  None  the  less,  attempts 
have  been  made  to  restore  movement  to  a  stifTened  knee,  and  it  is  necessary 
to  make  some  record  of  these  attempts.  Before  any  operation  of  this  nature 
is  tried  it  is  most  essential  to  satisfy  one's  self  that  the  original  disease  is 
entirely  cured.  Latent  tubercle  lying  in  the  interior  of  the  bone  may  easily 
be  lighted  up  by  such  manipulation. 

Murphy's  Operation. — Murphy  practises  an  operation  very  similar  to 
that  which  he  employs  in  cases  of  hip  ankylosis,  the  essential  feature  of 
which  is  the  introduction  of  a  connective  tissue  flap  between  the  separated 
osseous  surfaces  in  the  hope  that  a  new  synovial  cavity  may  be  formed, 
liriofiy,  the  operation  is  as  follows  : 

Bleeding  is  controlled  by  a  tourniquet.  A  long  external  incision  is 
made  from  a  point  6  inches  above  to  a  point  3  inches  below  the  knee-joint. 


278  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

The  incision  is  comparatively  superficial  except  over  the  joiat,  the  remains 
of  which  it  opens.  A  vertical  4-inch  incision  is  made  over  the  inner  side  of 
the  joint.  Through  these  incisions  the  lateral  ligaments  are  divided  and 
removed.  The  ankylosis  is  now  reduced,  the  patella  is  lifted  from  the  femur 
with  a  chisel,  and  the  femur  is  separated  from  the  tibia  with  chisel  or  saw. 
The  lower  end  of  the  femur  is  trimmed  to  a  convex  shape,  the  upper  end  of 
the  tibia  to  one  correspondingly  concave.  From  the  outer  surface  of  the 
vastus  externus  a  flap  of  muscle  and  fascia  with  the  base  downwards  is 
detached.  The  flap  must  be  so  planned  that  it  extends  laterally  across 
the  joint,  and  antero-posteriorly  covers  over  the  entire  raw  osseous  surface. 
The  flap  is  fastened  in  position  with  interrupted  catgut  sutures.  A  smaller 
flap  is  similarly  interposed  between  the  patella  and  the  femur.  The  after 
treatment  consists  in  keeping  the  limb  rigid  and  extended  for  one  week. 
At  the  end  of  that  time  massage  and  movements  are  begun. 

Joint  Transplantation,— In  1908  Lexer  ^  described  two  cases  in 
which  he  had  overcome  an  ankylosis  by  transplanting  the  entire  knee-joint. 
In  one  case  the  ankylosis  had  occurred  in  a  flexed  position  as  the  result  of 
tuberculous  disease,  in  the  other  instance  acute  suppuration  was  responsible. 
The  operation  is  carried  out  by  exposing  the  remains  of  the  joint  through  an 
anterior  curved  incision.  The  soft  parts  are  separated  laterally  from  the 
neighbourhood  of  the  joint,  and  the  synostosis  is  excised.  With  the  limb 
extended  there  now  exists  between  the  femur  and  tibia  a  space  of  about 
1^  inches  in  extent.  Into  this  gap  a  healthy  knee-joint,  from  a  freshly 
amputated  limb,  is  introduced  and  accurately  fitted.  The  implant  is  fixed 
in  position  by  means  of  wire  sutures  or  nails.  The  skin  flap  is  brought  into 
position,  and  the  continuity  of  the  ligamentum  patellae  restored.  In  Lexer's 
cases  healing  by  first  intention  occurred  in  both  instances.  The  present 
result  is  said  to  be  one  of  slight  movement,  and  no  pain  on  walking  or  standing. 

Ankylosis  of  Patella  to  Femur.  —  Cases  have  been  described  in 
which  local  disease  has  produced  fixation  of  the  patella  to  the  femur,  the 
rest  of  the  joint  being  healthy.  Such  a  fixation  necessarily  means  complete 
immobility.  It  is  possible  to  correct  such  a  complication  by  separating 
the  patella  from  the  femur  and  interposing  between  the  surfaces  a  flap  of 
muscle.  The  region  is  exposed  by  a  longitudinal  incision  on  the  inner  side 
of  the  patella,  the  muscular  flap  is  obtained  from  the  vastus  internus. 

BIBLIOGRAPHY 

Pathology 

Barbarin.  "  De  rallongement  atrophique  de.s  o.s  du  raembre  inferieur  dans  la  tumeur  blanche 
du  genou  chez  I'enfant,"  Rev.  d'orthop.,  Pari.s,  1908,  2<'  ser.  ix.  182-184. 

Defais,  a.  "  Contribution  a  I'etude  des  synoviales  tuberculeuses  a  graines  riziformes  de 
I'articulation  du  genou,"  Bev.  internal,  de  la  tuberc,  Paris,  1909,  xv.  426-432. 

Symptoms  and  Physical  Signs 

Swan,  R.  L.  "  A  Clinical  Lecture  on  a  Reference  to  some  Tubercular  Diseases  of  the  Knee- 
joint  and  to  the  Treatment  of  Synovial  Cavities,"  Med.  Press  and  Circ,  London,  1907, 
N.S.,  Ixxxiv.  542. 

'  Lexer,  Archiv  fiir  klin.  Chir.  Ixxxvi.  952. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT  279 

Bakbarin,  p.     "  Les  Attitudes  vicieuses  dans  les  turaeurs  blanches  du  genou  chez  I'enfant : 

leurs  causes,  leur  traitement,"  Clinique,  Paris,  1907,  ii.  773-777. 
Broca,  a.      "  A  propos  de  3  cas  de  tuberculose  da  genou,"  Pedlatrie  prat.,  Lille,  1910,  viii. 

301-306. 
Drem,  D.      "  Tuberculous  Synovitis   of   Knee-joint,  etc.,"   Proc.  Roy.  Soc.  Med.,  London, 

1907-8,  i.,  Clin.  Sect.  10. 
Johnson,    R.      "  Enlarged    Knee-joint,    probably    Tuberculous,"    Clin.    Journal,    London, 

1908-9,  xxxiii.  63. 
Lanz,  O.     "  Gonarthritis  tuberculosa,"  Nederl.  Tijdschr.  v.  Getiusk.,  Amsterdam,  1908,  ii.  69H 
Van  Kaatoven,  J.  .J.  A.     "  A  Case  of  Tuberculous  Arthritis  of  the  Knee,  apparently  much 

aggravated  by  Biers  Congestion,"  Therap.  Gaz.,  Detroit,  1908,  xxxii.  170-172. 
SwYNGHEDAUW.     "  Tumeur  blanche  du  genou,"  Echo  med.  du  nord,  Lille,  1908,  xii.  252 
Cabanas,  E.     "  Tuberculose  et  ankylose  vicieuse  du  genou,"  Bull.  med.  de  I'Algerie,  Algeria. 

1908,  xix.  284. 

DuvERC.EY,    J.     "  La    Tuberculose    du    genou    circonscrite    au     cul-de-sac    quadricipital," 

Gaz.  hebd.  des  sc.  med.  de  Bordeaux,  1908,  xxix.  397-400. 
Barbarin,  p.     "  Les  Durations  consecutives  a  la  tumeur  blanche  d\i  genou  chez  I'enfant : 

leur  mechanisme,  leur  traitement,"  Paris  chirurg.,  1909,  i.  533-539. 
Rives,  A.     "Tumeur  blanche  du  genou,"  Montpel.  med.,  1909.  xxviii.  38-41. 
Peckiiam,  F.   E.,  and  Hammond,  R.     "  Ankylosis  of  the  Knee  following  Tuberculosis," 

Boston  M.  and  S.  J.,  1909,  clx.  447. 
Sternhardt,  L  D.     "  Tuberculosis  of  the  Knee-joint,"  New   York  M.  Journal,  1909,  xc. 

395-398. 
DnpUY  de  Fbenella.     "  Les  Deviations  dans  les  tumeurs  blanches  du  genou  chez  I'enfant," 

Paris  chirurg.,  1909,  i.  723-725. 
JuDET.     "  Les  Deviations  dans  les  tumeurs  blanches  du  genou  chez  I'enfant,"  Paris  chirurg., 

1909,  i.  651-656. 

Waitiker.     '■  Tumeur  blanche  du  genou,"  Bull,  et  mem.  Soc.  de  Chir.  de  Par.,  1909,  N.S., 

sxxv.  1154-1156. 
Broca,  A.     "  A  Propos  de  3  cas  de  tuberculose  du  genou,"  Pediatric  prat.,  Lille,  1910,  viii. 

301-306. 
Broca,  A.     "  Les  Attitudes  vicieuses  dans  la  tumeur  blanche  du  genou,"  Pediatric  prat., 

Lille,  1910,  viii.  323-326. 
Addison,  O.  L.     "  Old  Healed  Tuberculous  Disease  of  Knee-joint :  Increase  in  Length  of 

Limb,"  Proc.  Roy.  Soc.  Med.,  London,   1910-11,  iv..  Sec.  Stud.  Dis.  Clin.  39. 
FlDON.     "  Tuberculose  du  genou,  etc.,"   Bull.  Soc.  Me.d.  Chir.  de  la  Drome,  Valence,  1910, 

xi.  56-59. 
SiiERiLE,  J.  G.     "  Observations  on  the  Surgery  of  the  Knee-joint,"  Surg.  Gxjn.  and  Obstetr., 

Chic.,  1910,  X.  205-207. 
Mathews,  F.  S.     "  Tuberculous  Synovial  Cionitis,"  Ann.  Surg.,  Philadelphia,  1910,  Ii.  946. 
Du  Croquet,  C,  and  Beau,  U.     "Les  Deviations  du  genou  dans  la  tumour  blanche,"  Arch. 

de  med.  d'enf.,  Paris,  1911,  xiv.  241-249. 

Diagnosis 

GuiRiN,  A.     "  Diagnostic  d'evolution  tuberculeuse  de  I'hemarthroso  du  genou,"  Rev.  gen 
de  din.  et  de  therap.,  Paris,  1909,  xxiii.  201. 

Treatment 

Hammond,  VV.  N.      "  The  Modern  Surgical  Treatment  of  Knee-joint  Diseases,"  Hahneman 

Month.,  Philadelphia,  1909,  xliv.  749-7.53. 
Impallomeni,  (!.     "  Lo  Traitement  de  I'osteoarthrito  tul)crculeuse  du  genou  chez  I'enfant 

doit  etre  resolument  conscrvateur,"  Rev.  d'orlhop.,  Paris,  1909,  2°  s6r.  x.  501-536. 
De  Vbeese,  C.     "  Nouveau  Traitement  de  I'hvdarthrose  du  genou,"  Ann.  Soc.  d'Anvers,  1910, 

Ixxii.  131-137. 
Zeldovich,  Y.  1$.     "  Treatment  of  Tuberculosis  of  the  Knee-joint,"  Ru.i.ik.  Xach.,  St.  Peters- 
burg, 1911,  X.  H42,  876,  911. 
Charkur,  A.     "  Kesiillats  I'loignes  du  traitement  de?  tumeurs  blanehes  du  genou  par  les 

injections  profoiidis  ilc  chloride  de  zinc,"  Gaz.  hebd.  des  sc.  med.  de  Bordeaux,  1911,  xxxii. 

7.5. 
BiDOU,  A.     J)u  traitement  aclud  de  la  tumeur  blanche  du  genou,  Lyons,  1912. 
Baldwin.     "  Tuberculous  Disease  of  the  Knoe-joint,"  West  London  M.J.,  London,  1913, 

xviii.  39. 
Gallocun.     "  Osteoarthritis  tuberculeuse  du  genou,"  Normandie  med.,  Knuen,  1913,  xxix. 

10-15. 


280  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

Operative  Treatment  of  Knee-joint  Disease 

Davis,  H.     "  Secondary  Excision  of  the  Knee-joint,"  St.  Earth.  Ho.9p.  Reps.,  1908,  London, 

1909,  xliv.  143-151. 
Ferguson,  A.  H.     "  Excision  of  the  Knee-joint,"  Sii.rg.  Gyn.  and  Obstelr.,  1908,  vi.  68-71. 
Bekger.     "  Les  Indications  operatoires  dans  la  tumeur  blanche  suppuree  du  genou,"  Rev. 

gen.  de  chir   et  de  therap.,  Paris,  1908,  xxii.  38. 
Lbnhart,  H.     "  Beitrag  zur  Resektion  des  tuberkulosen  Kniegelenks,"  Beitr.  z.  klin.  Chir., 

Tubingen,  1909,  Ixi.  455-477. 
Clarke,  J.  J.     "  Excision  of  the  Knee-joint,"  Polyclin.,  London,  1909,  xiii.  40. 
Crespolti.     ''  La  Resezione  del  ginocchio  per  osteomyelite  tubercolare,"  Gaz.  internaz.  di 

med.,  Napoli,  1909,  xii.  62. 
Edmunds,  A.     "  Arthrectomy  of  the  Knee-joint,"  3Ied.  Press  and  Circ,  London,  1909,  N.S., 

Ixxxvii.  581. 
Lehr,  H.     "  Die  Resektiondeformitat  des  Kniegelenks  :  ein  Beitrag  zur  Frage  der  operativen 

Oder  konservativen  Behandlung  der  Kniegelenkstuberkulose  in  Kindesalter,"  Zeitschr. 

fur  orth.  Clin.,  1909,  xxiii.  529-556. 
Gibney,  V.   P.     "  The  Part  Arthrectomy  plays  in  the  Treatment  of  Tuberculous  Joints, 

more  particularly  the  Knee-joint,"  Amer.  Journ.  Orth.  Surg.,  1909-10,  vii.  22-30. 
Olliviek.     "  Resection   sans   drainage   pour    un    arthrite    tuberculeuse    du   genou,"    Lyon 

chirurg.,  1910,  iv.  68-74. 
MoREAU,  J.     "  Resection  totale  du  genou   pour  tumeur  blanche,"  Clinique,  Brux.,  1912, 

xxvi.  679-695. 


TUBERCULOUS  DISEASE  OF  THE  ANKLE-JOINT  281 


TUBERCULOUS  DISEASE   OF  THE  ANKLE-JOINT 

Etiology 

It  is  generally  stated  that  tuberculous  disease  of  the  ankle-joint  ranks 
third  in  the  order  of  occurrence,  taking  in  the  sequence  next  place  to  disease 
of  the  knee-joint. 

The  illustrative  statistics  most  frequently  quoted  are  those  of  Whitman.^ 
In  five  consecutive  years  1788  cases  of  tuberculous  disease  of  the  joints  of 
the  lower  extremity  were  treated  at  the  outdoor  department  of  the  Hospital 
for  Ruptured  and  Crippled.  In  54-1  per  cent  of  these  the  hip-joint  was 
affected,  in  36-2  per  cent  the  knee-joint,  and  in  but  9-7  per  cent  the  ankle- 
joint.  Statistics  obtained  over  a  period  of  ten  years  from  the  Edinburgh 
Sick  Children's  Hospital  show  somewhat  different  results.  Considering 
tuberculous  joints  of  all  varieties  the  ankle  was  found  to  constitute  a  pro- 
portion of  15-.5  per  cent.  This  difference  is  probably  to  be  explained  by  the 
fact  that  while  ^\^litman's  results  were  obtained  from  cases  of  all  ages, 
the  Edinburgh  figures  are  drawn  entirely  from  children  less  than  twelve 
years  old.  In  comparison  with  the  occurrence  of  tuberculous  joint  disease 
in  other  situations  ankle  disease  is  more  common  in  childhood  than  in  later 
life.  It  is  more  common  in  boys  than  in  girls  in  the  proportion  almost  of  2 
to  1.  The  increased  occurrence  of  injury  in  the  male  sex  has  b?en  made 
responsible  for  the  greater  proportion  in  boys. 

Pathology 

Anatomy  of  the  Joint. — The  bones  which  enter  into  the  formation 
of  the  ankle-joint  arc  the  lower  ends  of  the  tibia  and  fibula  and  the  astragalus. 
The  tibia  and  fibula,  aided  by  the  transverse  inferior  tibio-fibular  ligament, 
form  a  three-sided  socket  within  which  the  astragalus  is  accommodated. 
The  joint  is  completely  invested  by  ligaments,  aiul,  with  the  exception  of  the 
anterior,  they  are  of  considerable  strength.  Synovial  membrane  lines  the 
capsular  ligament,  and  the  joint  cavity  communicates  directly  with  the 
inferior  tibio-fibular  joint.  The  movements  of  which  the  joint  is  capable 
are  those  of  dorsi-flexion  and  extension  ;  it  is  extremely  d()ul)tful  whether 
any  degree  of  lateral  movement  is  possible. 

Patholog'ical  Anatomy.  The  actual  ))iithology  differs  in  no  respect 
from  tliat  \vlii(  h  lias  Ijrcii  described  in  other  situations.  I'lider  tiiis  heading 
one  nnist  discuss  the  exact  location  of  the  disease,  and  tliis  question  is  com- 
plicated by  the  proximity  of  the  ankle-joint  to  the  tarsal  hones  and  .synovial 

'  Wliitnmn,  he.  cil.,  p.  440. 


282  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

sacs.  Hahn  ^  has  published  an  investigation  of  the  situation  of  the  disease 
as  ilhistrated  by  a  series  of  309  cases.  Of  these,  .51  per  cent  had  apparently 
originated  in  the  bone,  the  remainder  were  primarily  synovial.  The  situa- 
tion of  the  osseous  lesion  varied  \vithin  wide  limits.  The  primary  focus 
was  in  the  internal  malleolus  in  11  instances,  in  the  external  in  7,  and  in  5 
both  tibia  and  fibula  were  affected.  In  116  cases  the  disease  had  begun 
in  the  astragalus,  in  16  instances  in  the  os  calcis,  and  in  5  both  astragalus  and 
OS  calcis  were  diseased.  During  the  past  ten  years  29  cases  were  operated 
on  in  the  Edinburgh  Sick  Children's  Hospital.^  The  disease  was  primarily 
syno\aal  in  6  cases,  while  in  23  it  was  both  synovial  and  osseous.  The 
astragalus  was  involved  in  15  cases,  the  os  calcis  in  5,  the  tibia  and  fibula  in 
2,  and  the  scaphoid  in  1.  It  was  more  especially  observed  that  when  the 
astragalus  was  diseased,  the  focus  was  originally  localised  to  the  neck  of 
the  bone.  Statistics  therefore  appear  to  indicate  that  the  neck  of  the 
astragalus  is  the  situation  of  choice  in  which  the  disease  begins.  This 
distinctness  and  peculiarity  of  origin  is  to  be  explained  upon  anatomical 
grounds.  If  the  popliteal  artery  of  a  limb  is  injected  with  a  solution  of 
lampblack,  and  the  bones  afterwards  cut  and  examined,  it  will  be  found  that 
a  considerable  quantity  of  the  injection  becomes  deposited  in  the  interior 
of  the  neck  of  the  astragalus.  The  deposit  is  usually  sufficient  to  produce 
a  distinct  blackened  area  in  this  portion  of  the  bone.  The  injection  has 
collected  in  this  situation,  because  the  part  is  an  exceedingly  vascular  one. 
Its  vessels  originate  from  those  around  the  synovial  reflection,  and  they 
extend  into  the  interior  of  the  bone,  at  the  attachment  of  the  anterior  liga- 
ment to  the  neck.  As  one  finds  anatomically,  so  one  finds  clinically,  tuber- 
culous disease  of  the  ankle-joint  is  mainly  osseous  in  origin,  and  its  origin  is 
more  especially  localised  to  the  neck  of  the  astragalus.  From  the  original 
deposit  in  the  neck  of  the  astragalus  the  disease  may  extend  in  various 
directions.  It  may  pass  directly  to  the  surface  in  front  of  or  behind  the 
anterior  ligament  of  the  joint.  If  in  front  of  the  anterior  ligament,  it  forms 
an  extra-articular  cold  abscess  upon  the  dorsum  of  the  foot ;  if  posterior  to 
the  ligament,  it  invades  the  ankle-joint  directly.  Its  other  possible  direc- 
tion is  backwards  into  the  body  of  the  astragalus,  from  which  it  secondarily 
usually  invades  the  joint.  Sometimes  it  makes  its  way  forwards  into  the 
astragalo-scaphoid  joint,  and  eventually  into  the  various  bones  of  the  tarsus. 
The  surrounding  tendons  are  in  such  close  proximity  to  the  ankle-joint  that 
they  soon  become  infected,  and  the  disease  spreads  upwards  and  downwards 
along  the  sheaths. 

Symptoms  and  Physical  Signs 

Limp. — Perhaps  the  earliest  symptom  of  ankle-joint  disease  is  a  slight 
limp.  At  first  it  is  noticed  only  after  unusual  exertion,  but  it  becomes  more 
persistent  until  it  is  permanently  established.     In  its  beginnings  the  limp 

1  Hahn,  Beiirage  zur  klin.  Chir.,  Bd.  xxvi.  H.  2,  1900. 
2  Stiles,  Brit.  Med.  Jour.,  Nov.  16,  1912. 


I'l.A'I'IO  X[.\\.     Ai)V\NrK[)  'l'i;ni;iii.'i:r.()fs  Diskask  iik  tmk  AmvI.k-.Ioint. 
Sectiiiic  of  till'  Iniit  >liciw,s  lli;vt  IIh-  iliscnse  angiiuite<l  in  tlio  nt'i-k  (if  llie  iistrn^iilus. 


TUBERCULOUS  DISEASE  OF  THE  ANKLE-JOINT  283 

appears  to  be  due  to  some  hesitation  in  the  free  flexion  of  the  ankle-joint. 
Fully  developed,  it  is  quite  obviously  the  result  of  a  fixed  deformity  in  the 
position  of  equino-valgus. 

Pain. — Pain  is  complained  of  very  soon  after  the  patient  becomes  lame. 
The  pain  is  indicated  as  occurring  on  the  front  of  the  joint  and  around  both 
malleoli.  In  the  earliest  stages  of  the  disease  it  may  be  induced  by  plantar 
flexion  of  the  foot  and  putting  the  anterior  ligament  of  the  joint  upon  the 
stretch,  tension  being  then  exerted  on  the  diseased  area  in  the  neck  of  the 
astragalus.  Pain  is  afterwards  exaggerated  by  all  movements,  and  it  is 
intensified  by  direct  pressure  upon  the  os  calcis. 

Position. — There  is  much  that  is  characteristic  in  the  position  of  the 
foot.  In  early  disease  the  ankle  is  held  slightly  dorsi-flexed  in  order  to  relax 
the  anterior  ligament,  and  so  to  minimise  the  irritation  of  the  disease  at  the 
neck  of  the  astragalus.  In  the  more  fully  developed  condition  the  position 
is  one  of  plantar  flexion  or  of  equino  valgus.  The  equinus  posture  is  adopted 
to  reduce  the  chance  of  weight  bearing  by  the  os  calcis,  and  is  partly  the  result 
of  the  action  of  gravity.  The  valgus  attitude,  often  so  characteristic,  is 
somewhat  difficult  to  explain.  It  may  be  induced  by  the  continual  use  of 
the  limb  in  the  passive  attitude,  but  it  has  been  suggested  that  the  intention 
is  to  relax  the  peroneus  longus,  because  from  the  sling-like  arrangement 
of  this  muscle  its  contraction  exerts  a  force  in  the  long  axis  of  the  limb, 
which  is  largely  borne  by  the  ankle-joint. 

Gait. — The  patient  walks  with  the  gait  peculiar  to  that  of  a  stiff  ankle- 
joint.  In  the  later  stages  the  toes  are  held  pointing,  and  in  walking,  weight 
is  borne  upon  them. 

Swelling. — Swelling  makes  its  appearance  early,  or  rather  it  is  early 
appreciated  on  account  of  the  close  relationship  of  the  joint  to  the  surface. 
It  is  first  noticed  at  the  front  of  the  joint  as  a  uniform  fulness  beneath  the 
extensor  tendons.  As  the  infection  becomes  general  throughout  the  joint 
there  is  swelling  around  the  outlines  of  the  malleoli.  From  the  situation  and 
distribution  of  the  swelling  one  is  able  to  form  an  idea  of  the  origin  of  the 
disease  and  the  course  which  it  is  taking.  A  synovial  tuberculosis  confined 
to  the  ankle-joint  is  evidenced  by  swelling  around  the  malleoli.  Astragaloid 
disease,  while  closely  simulating  ankle-joint  disease,  gives  rise  to  a  swelling 
at  a  lower  level  and  confined  to  the  front  of  the  foot. 

Palpation  of  the  ankle-joint  will  confirm  much  that  inspection  has  taught 
one.  An  increase  of  local  temperature  may  be  noted.  The  outline  of  the 
synovial  thickening  is  palpated,  and  its  peculiar  boggy  character  appreciated. 
Free  fluid  may  be  demonstrated  within  the  joint,  though  it  is  nuich  less 
common  in  this  situation  than  it  is  in  the  knee.  The  bones  are  carefully 
palpated  and  compared  with  those  of  iIh'  opixisitc  .side  ;  it  may  be  possible  to 
appreciate  a  thickening  which  iiidiciitrs  disease  n[  the  underlying  bone. 

The  movemeyits  at  the  ankle-joint  are  tested.  It  must  be  remembered 
that  dorsi-flexion  and  ]ilantar-flexion  arc  the  only  movements  of  which  the 
ankle-joint  is  capaijle.  Inversion  and  eversion,  abduction  and  adduction, 
take  place  at  the  niid-tarsal  joint,     'i'herefore,  in  the  examination  of  the 


284  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

disease  the  ankle-joint  movements  are  limited  or  abolished,  while  the  mid- 
tarsal  ones  are  not  interfered  wath  unless  the  disease  has  extensively  involved 
the  tarsus. 

Accompanying  the  limitation  of  movement  there  is  a  related  muscular 
spasm.  In  neglected  cases  peri-articular  abscesses  become  evident,  and  the 
seat  of  election  in  which  they  appear  is  around  the  internal  or  the  external 
malleolus.  These  sites  are  chosen  because  the  infection  makes  its  way  to 
the  surface  in  the  ligamentously  weak  spaces  which  occur  in  front  of  or  behind 
the  lateral  ligaments.  Sinuses  frequently  follow  the  appearance  of  abscesses. 
They  usually  lead  directly  into  the  joint.  If  they  are  located  at  some  distance 
from  the  joint,  they  have  probably  developed  from  an  underlying  tendon 
disease. 

X-Ray  Examination. — It  is  essential  that  a  radiogram  be  taken.  From 
the  peculiar  anatomy  of  the  ankle-joint  and  foot  a  single  negative  is  often 
insufficient ;  it  is  well  therefore  to  be  provided  with  two,  one  antero-posterior 
and  one  lateral.  By  an  X-ray  examination  one  is  able  to  come  to  a  conclusion 
regarding  the  exact  situation  and  extent  of  the  disease.  Attention  has 
elsewhere  been  drawn  to  the  rarefying  changes  which  occur  in  an  otherwise 
healthy  bone,  when  it  is  in  the  neighbourhood  of  a  tuberculous  bone  or  joint ; 
this  point  is  well  illustrated  in  the  ankle-joint  and  tarsus.  In  an  X-ray 
photograph  of  a  tuberculous  ankle,  the  bones  of  the  tarsus  may  appear  as 
empty  shells,  so  great  is  the  internal  rarefaction. 

Diagnosis 

There  is  little  chance  of  mistaking  a  tuberculous  ankle  for  any  other 
condition.  A  chronic  disease,  confined  to  a  single  joint,  occurring  in  a  child 
and  accompanied  by  muscular  spasm  and  deformity,  is  almost  certainly 
tuberculous  in  origin.  The  diagnosis  is  more  difficult  in  adults,  but  with  that 
we  have  nothing  to  do. 

Actual  Diag-nosis 

The  actual  diagnosis  is  made  by  observing  : 

(1)  Swelling. — An  early  evidence  of  the  disease  is  a  fulness  upon  the  front 
and  lateral  aspects  of  the  joint.  The  swelling  gives  a  characteristic  spindle- 
shaped  appearance  to  the  joint,  and  it  is  accompanied  by  muscular  wasting. 

(2)  Gmt  and  Position  of  Foot. — The  patient  walks  lame.  It  is  important 
to  observe  the  sequence  of  alterations  in  position  from  dorsi-flexion  to 
plantar-flexion  and  to  equino-valgus. 

(3)  Pain  ami  Tenderness  with  Muscular  Rigidity. 

Differential  Diagnosis 

In  considering  the  differential  diagnosis  there  are  in  children  only  two 
conditions  which  could  be  mistaken  for  tuberculous  disease  of  the  ankle- 
joint — these  are  a  chronic  traumatic  synovitis  and  tuberculosis  of  the  tarsus. 
In  chronic  traumatic  synovatis  there  is  an  absence  of  the  elastic  boggy 
swelling  which  is  peculiar  to  tuberculous  disease,  there  is  much  less  pain, 


-      so 


TUBERCULOUS  DISEASE  OF  THE  ANKLE-JOINT  285 

and  little  or  no  local  tenderness.  If  the  foot  is  uniformly  swollen  and  sinuses 
are  present  it  may  be  difficult  to  decide  whether  the  disease  is  affecting  the 
ankle-joint  or  the  tarsus.  Usually  a  distinction  may  be  made  by  the  position 
of  the  swelling  and  by  the  alteration  in  special  movements.  When  the  ankle- 
joint  is  diseased  plantar-flexion  and  dorsi-flexion  are  interfered  with  ;  when 
the  tarsal  joints  are  affected,  inversion  and  eversion  are  probably  limited. 

Prognosis 

There  are  a  few  special  points  to  be  drawn  attention  to.  If  the  disease 
is  treated  early  the  prospect  of  ultimate  recovery  is  exceedingly  good.  In- 
vasion of  the  tarsal  bones  greatly  increases  the  gravity  of  the  prognosis. 
It  is  well  to  remember  that  a  cure  of  a  tuberculous  ankle  is  sometimes 
followed  by  a  troublesome  flat  foot,  the  result  of  weakening  of  the  overlying 
ligaments. 

Treatment 

General  Treatment. — It  is  unnecessary  to  repeat  what  has  already 
been  fully  dealt  with.  General  treatment  is  as  important  as  it  is  in  any  other 
form  of  tuberculosis.  As  a  rule,  the  application  of  suitable  splints  allows  the 
child  to  retain  almost  the  activity  of  full  health,  and,  therefore,  there  can  be 
no  excuse  for  the  neglect  of  proper  hygienic  surroundings. 

Local  Treatment. — The  same  principles  apply  to  the  ankle  as  to  other 
joints.  Fixation,  rest,  and  protection  are  the  essential  lines  of  treatment. 
and  they  may  be  reinforced  by  such  means  as  injections,  passive  congestion, 
and  tuberculin. 

Methods  of  Fixation. — Extension. — On  account  of  the  peculiar  outline 
of  the  ankle-joint  it  is  difficult  to  apply  any  form  of  satisfactory  extension. 
It  may  be  accomplished  by  fastening  fan-shaped  extension  plasters  to  each 
side  of  the  joint  passing  across  the  ankle-joint  in  front  and  behind.  That 
portion  of  each  strap  which  corresponds  to  the  handle  of  the  fan  is  fastened 
in  the  usual  way  to  a  stirrup  and  weights.  In  applying  extension  by  this 
method  the  danger  to  be  guarded  against  is  a  dragging  downwards  of  the 
toes  and  the  acquisition  of  an  oquiiuis  deformity.  Extension  would  be 
called  for  in  the  presence  of  persistent  pain  and  muscular  spasm. 

Plaster  of  Paris. — The  ankle-joint  is  esjjecially  well  adapted  to  treatment 
by  plaster  of  Paris.  The  toes  are  left  exposed,  and  the  case  is  carried  up 
the  leg  as  far  as  the  garter  line.  Care  must  be  taken  to  see  that  the  foot  is 
at  right  angles  to  the  leg  whik-  the  plaster  is  being  applied.  It  is  sometimes 
recommended  that  windows  bo  cut  out  over  each  malleolus,  to  avoid  the 
risk  of  pressure  sores  and  to  provide  suitable  observation  of  the  joint.  One 
uses  the  plaster  case  almost  as  a  routine  method.  If  the  disease  is  acute 
and  accompanied  by  pain  I  lie  plaster  is  applied  and  the  patient  kept  in  bed. 
The  urgency  of  the  symptoms  soon  disa]i]iears,  and  the  patient  is  allowed 
up.  using  crutehos  and  a  patten  u])on  the  opposite  foot. 

If   the   syni[itoms  are   not  acute    ambulation   is   ijorniittcd    from   the 


286 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


beginning.  The  patient  is  strictly  warned  against  bearing  any  weight  on 
the  foot,  and  if  there  is  any  likelihood  of  these  instructions  being  disregarded 
a  Thomas  knee  splint  is  applied  in  addition  to  the  plaster  case.  In  the 
presence  of  sinuses,  windows  are  cut  from  the  plaster  to  permit  of  the 
dressing. 

Jones  Crab  Splint. — In  the  event  of  plaster  of  Paris  being  either  un- 
suitable or  non-available,  the  crab  splint  may  be  employed.  It  consists  of 
a  piece  of  sheet  iron  hollowed  to  fit  the  upper  two-thirds  of  the  posterior 
surface  of  the  leg.  To  this  is  riveted  a  flat  bar  of  iron  |  x  x(j  inch  or  such  size 
as  will  hold  the  part  firmly,  and  it  is  bent  to  follow  approximately  the  out- 
line of  the  back  of  the  ankle  and  heel  to  the  middle  of  the  sole  of  the  foot. 
At  the  point  where  it  passes  round  the  bend  of  the  heel  there  is  riveted  a  cross 
piece  of  iron  reaching  two-thirds  around  the  ankle,  of  such  thickness  as  can 

be  bent  by  the  hand,  and 
at  the  end  of  the  main  bar 
is  riveted  another  piece  of 
like  metal  long  enough 
nearly  to  encircle  the  foot 
at  that  point.  The  whole 
may  be  japanned  and 
applied  over  a  thin  layer  of 
cotton,  or  it  may  be  covered 
with  leather  without  pad- 
ding and  applied  next  to 
the  skin.  The  splint  is 
bent  to  grasp  the  foot  as 
accurately  as  possible,  and 
held  in  place  by  a  strip 
of  adhesive  plaster  and  a 
roller  bandage.^ 

The  duration  of  the 
period  of  complete  fixa- 
tion will  extend  over  at 
least  twelve  months.  If,  at  the  end  of  that  time,  there  are  still  evidences  of 
disease  in  the  shape  of  pain  or  muscular  rigidity  the  fixation  treatment 
must  be  continued.  If  the  signs  are  propitious  the  second  stage  of  treatment 
is  begun.  The  essential  feature  of  it  is  that  while  movements  can  be  carried 
out  at  the  joint  no  weight  is  permitted  to  be  borne  by  the  part.  These 
requirements  are  fulfilled  by  the  use  of  a  Thomas  knee  splint.  The  ankle- 
joint  is  freed  from  all  fixation,  the  Thomas  splint  is  applied,  and  with  the 
limb  dependent  within  it,  movement  of  the  ankle-joint  is  begun  without  any 
weight-bearing  being  permitted. 

It  is  usually  necessary  to  continue  the  use  of  the  Thomas  knee  splint 
for  a  period  of  six  months.  It  is  then  discarded  and  the  foot  is  gradually 
allowed  to  resume  its  normal  range  of  movement.     The  course  of  treatment 

'  Contribution  to  Orthopcedic  Surgery,  Jones  and  Ridlon,  p.  214. 


Fig.  139.- 


-The  crab  splint  for  use  in  tuberculous  disease  of 
the  ankle-joint  (Jones  and  Ridlon). 


TUBERCULOUS  DISEASE  OF  THE  ANKLE-JOINT  287 

extending  over  two  years,  which  is  here  outlined,  may  require  to  be  extended 
in  the  event  of  the  symptoms  not  impro\ing  sufficiently. 

The  adjuncts  of  Bier's  treatment  and  tuberculin  treatment  require 
no  further  discussion.  The  former  is  eminently  suitable  for  ankle-joint 
tuberculosis.  Injection  of  the  joint  by  one  of  the  already  mentioned  medica- 
ments is  recommended,  more  especially  by  Calot.^  The  needle  is  entered 
in  the  front  of  the  joint  atthe  external  tibio-tarsal  angle.  Krause  punctures 
the  tissue  vertically  immediately  below  one  or  other  malleolus,  and  then 
directs  the  needle  point  upwards. 

The  Correction  of  Deformity.  —  Neglected  cases  of  the  disease 
acquire  a  deformity  of  equinus  sometimes  complicated  with  a  valgus  position. 
Under  anaesthesia  the  deformity  is  corrected,  and  a  splint  is  applied  to  main- 
tain the  proper  position.  If  the  malposition  is  of  long  standing,  it  may  be 
necessary  to  divide  the  tendo  achilles  before  the  deformity  can  be  corrected. 
Operative  Treatment. — Indications.  -The  conditions  under  which 
operation  becomes  necessary  are  similar  to  those  discussed  in  other  joints. 
Briefly  they  include  progression  of  the  disease  in  spite  of  treatment,  the 
formation  of  abscesses  and  sinuses,  extensive  involvement  of-  the  tarsus  or 
of  the  leg  bones,  and  failing  of  the  general  health. 

Varieties  of  Operation. — Out  of  a  number  of  methods  which  have  been 
introduced  for  exposure  and  excision  of  the  ankle-joint  those  essentially 
differing  in  detaU  will  be  described.  They  are  the  operations  associated  with 
the  names  of  Kocher,  Konig,  and  Ochsner. 

Kocher's  Operation. — The  feature  of  the  operation  is  a  dislocation  of 

the  foot  inwards  and  a  resulting  free  exposure  of  the  ankle-joint.     A  long 

J-shaped  incision  is  used.    It  extends  along  the  posterior  border  of  the  fibula 

for  about  2  inches,  curves  forwards  beneath 

the  tip  of  the  external  malleolus,  and  passes 

slightly  on  to  the  dorsum  of  the  foot  to 

end   at  the   edge  of   the  peroneus    tertius 

tendon.      With  division  of  the  skin    and 

superficial    fascia    the    external   saphenous 

vein  and  nerve  are  exposed  and  preserved. 

The  sheaths  of  the  peroneus  longus  and 

brevis  tendons  come  into  view.     They  are 

opened  upwards  and  downwards  along  the 

full  extent  of  the  wound,  and  the  tendons 

are  divided  with  the  knife  a  short  distance 

in  front  of  the  external  malleolus.     Through 

each  cut  end  a  silk  suture  is  passed  and  ^^^  uo.-KocIht's  in,isio„  for  excision 

secured  with    artery   forceps  ;    if   different  of  tlif  mikiejoint. 

types  of  forceps  are  used  for  each  tendon 

the  subsequent  recognition  and  approximation  are  facilitated. 

The  jjoriostcum  is  separated  from  the  outer  and  under  asi)ect  of  the 

external  malleolus,  and  the  flap  of  soft  tissues  is  retracted  strongly  ii\wards. 
'  Cal6t,  Orthopadie  indispensable,  p.  540. 


288  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

With  the  retraction  of  the  reflected  tissues  the  outer  part  of  the  anterior 
ligament  of  the  joint  comes  into  view.  The  interior  of  the  ankle-joint  will 
almost  certainly  have  been  opened  at  the  outer  edge  of  the  anterior  ligament 
where  it  joins  the  anterior  fasciculus  of  the  external  lateral  ligament,  and 
this  aids  the  division  of  the  anterior  ligament  with  scissors  across  the  front 
of  the  joint,  as  far  inwards  as  the  anterior  edge  of  the  internal  malleolus. 
The  three  bands  of  the  external  lateral  ligament  are  divided  near  the  tip 
and  on  the  inner  aspect  of  the  external  malleolus.  The  portion  of  the  anterior 
ligament  which  is  attached  to  the  lower  end  of  the  tibia  is  separated  upwards 
from  the  bone  together  with  the  periosteum.  A  similar  separation  of  tendon 
sheath  and  periosteum  is  carried  out  from  the  posterior  surface  of  the  fibula. 
The  foot  is  now  dislocated  inwards  exposing  the  complete  articular  surface. 
Should  the  dislocation  be  incomplete  it  is  rendered  more  complete  by  detaching 
the  posterior  and  transverse  ligaments  from  the  back  of  the  tibia.  A  study  of 
the  interior  of  the  joint  will  decide  the  necessary  extent  of  further  inter- 
ference ;  if  the  disease  is  confined  to  the  ankle-joint  it  may  be  sufficient 
to  remove  the  articular  surfaces  of  tibia,  fibula,  and  astragalus.  If  the 
astragalus  and  astragalo-calcanean  joint  are  diseased  it  becomes  necessary 
to  remove  the  whole  astragalus. 

To  remove  the  astragalus  its  head  should  first  be  freed.  This  is  done  by 
dividing  the  outer  attachment  of  the  lower  division  of  the  anterior  annular 
Ugament,  and  detaching  the  origin  and  posterior  part  of  the  extensor  brevis 
digitorum.  The  peroneus  tertius  and  extensor  tendons  are  retracted  well- 
upwards  and  inwards.  The  posterior  and  outer  part  of  the  astragalo-scaphoid 
capsule  is  now  exposed,  and  by  dividing  it  in  the  coronal  plane  the  head  of  the 
astragalus  is  laid  bare.  A  sharp  hook  is  inserted  into  the  astragalus,  and  while 
the  bone  is  dragged  upwards,  a  knife  is  introduced  beneath  it  so  as  to  divide 
the  strong  interosseous  ligament  between  it  and  the  os  calcis.  To  completely 
free  the  astragalus,  all  that  is  needed  is  to  detach  it  from  the  internal  lateral 
(deltoid)  ligament.  To  do  this  the  foot  is  forcibly  inverted  so  that  a  strong, 
sharp  hook  may  be  inserted  into  the  inner  surface  of  the  a.stragalus,  which  is 
dragged  downwards  and  outwards,  while  the  internal  lateral  ligament  is  divided 
close  to  the  bone,  or  separated  at  its  attachment  with  a  strong  sharp  rugine. 
By  keeping  close  to  the  bone  the  tendons  at  the  inner  ankle,  especially  the 
tibialis  posticus,  and  the  posterior  tibial  vessels  and  nerves  escape  iajmy.^ 

When  the  astragalus  has  been  removed,  the  upper  surface  of  the  os  calcis 
is  examined  and  freed  thoroughly  from  all  trace  of  disease.  The  foot  is 
now  returned  to  its  proper  position.  If  the  astragalus  has  been  retained, 
care  is  taken  to  see  that  its  pared  upper  surface  fits  accurately  into  the  new 
tibio-fibular  surface.  Should  it  have  been  necessary  to  remove  the  astrag- 
alus, the  upper  surface  of  the  os  calcis  is  suitably  modelled,  the  sustentacu- 
lum tali  removed,  and  the  external  malleolus  shortened.  Mr.  Stiles  has 
recommended  that  to  keep  the  bones  accurately  and  firmly  in  position  until 
the  process  of  healing  is  established,  a  long  square  steel  nail  should  be  driven 
from  the  sole  of  the  foot  through  the  os  calcis,  the  remains  of  astragalus  (if 
not  completely  removed),  and  into  the  tibia  for  an  inch  or  two.     The  remains 

1  Stiles,  A  System  of  Operative  Surgery,  edited  by  E.  F.  Burghard,  p.  85. 


TUBERCULOUS  DISEASE  OF  THE  ANKLE-JOINT  289 

of  the  separated  ligaments  are  united,  the  divided  peroneal  tendons  are 
resutured,  their  sheaths  repaired,  and  the  skin  edges  closed. 

Konig's  Operation. — Only  the  special  features  of  this  operation  will  be 
dealt  with.  It  is  most  valuable  in  cases  of  extensive  disease,  which  has 
extended  beyond  the  ankle-joint  and  involved  the  tarsal  bones.  An  incision 
is  made  along  the  antero-internal  aspect  of  the  joint,  beginning  2  inches 
above  the  ankle-joint  and  ending  at  the  prominence  of  the  scaphoid  ;  the 
incision  lies  over  the  neck  and  inner  side  of  the  astragalus.  A  similar  incision 
is  made  on  the  outer  side  of  the  ankle,  along  the  anterior  surface  and  margin 
of  the  fibula,  and  ending  at  the  astragalo-scaphoid  joint.  The  whole  bridge 
of  tissue  between  the  two  cuts  is  lifted  up  from  the  underlying  bones.  If 
the  foot  is  dorsi-flexed  a  good  view  can  be  had  of  the  front  of  the 
joint.  Before  the  posterior  part  of  the  joint  can  be  thoroughly  cleaned  the 
astragalus  must  be  removed.  The  succeeding  steps  of  the  operation  are 
similar  to  those  already  described.  The  value  of  the  method  lies  in  the 
fact  that  through  the  original  incisions,  not  only  the  ankle-joint  but  the 
astragalo-scaphoid  and  the  calcaneo-cuboid  joints,  with  their  respective 
bones,  can  be  examined  and  treated. 

Ochsner's  ^  Oferation. — Ochsner's  method  possesses  the  advantage  of 
afiording  exceedingly  good  access  to  the  joint,  but  the  benefit  is  counter- 
acted by  the  mutilation  which  is  necessary  in  obtaining  it.  An  incision  is 
carried  across  the  front  of  the  ankle-joint  from  malleolus  to  malleolus.  The 
extensor  tendons  are  divided,  and  for  purposes  of  identification  later  each 
is  secured  with  a  silk  suture  and  a  pair  of  forceps  of  distinctive  pattern.  The 
joint  is  opened  by  a  transverse  incision,  and  the  sole  of  the  foot  is  forced  back 
upon  the  calf  of  the  leg.  In  this  manner  the  entire  joint  is  opened  up,  and 
all  disease  can  be  removed.  When  this  has  been  accomplished  the  foot  is 
replaced  in  position.  The  tendons  are  carefully  sutured  and  their  sheaths 
restored.     The  skin  wound  is  then  closed. 

After- treat »wiU  of  Excision  of  the  Ankle. — A  simple  dressing  is  kept 
on  the  part  until  the  nail  has  been  removed  and  its  puncture  wound  healed, 
the  foot  is  then  placed  in  plaster  of  Paris.  The  plaster  case  is  kept  in  position 
for  about  three  months.  There  is  an  important  detail  regarding  the  boots 
which  these  cases  wear  afterwards.  After  the  operation,  more  especially 
when  the  astragalus  has  been  removed,  there  is  a  tendency  for  a  flat  foot 
to  occur,  this  can  be  partly  prevented  by  raising  the  sole  and  heel  of  the 
boot  upon  the  inner  side  to  the  extent  of  about  ^  an  inch.  It  is  sometimes 
an  advantage  to  have  a  light  plate  of  steel  fastened  to  the  sole  and  passing 
up  the  inner  side  of  the  l)0()t. 

The  Results  of  Excision  of  the  Ankle-joint. —  It  has  been  said 
that  tlie  results  of  excision  of  tlie  ankle-joint  are  not  as  a  rule  satisfactory. 
There  is  little  or  no  ground  for  this  assertion.  A  properly  performed  excision 
gives  exceedingly  good  results  both  as  regards  cure  of  the  disease  and  restora- 
tion of  function.     The  following  is  a  summary  of  Mr.  Stiles's  results.*     In  all, 

'■  Ochsnor,  Clinical  Surijery,  p.  727. 
«  Stilos,  liril.  Med.  Journ.,  Nov.  10,  1912. 

19 


290  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

29  cases  were  operated  on  and  25  were  afterwards  accounted  for.  The  actual 
extent  of  the  operation  varied  considerably.  In  6  cases  only  was  a  simple 
excision  performed,  i.e.  removal  of  the  articular  surfaces.  In  15  cases  it 
was  necessary  to  remove  the  astragalus,  in  5  the  os  calcis,  in  2  considerable 
portions  of  the  lower  end  of  tibia  and  fibula,  and  in  1  the  scaphoid.  There 
were  no  deaths  as  an  immediate  result  of  the  operation.  Within  one  year 
there  were  three  deaths,  one  from  broncho-pneumonia,  one  from  tuberculous 
meningitis,  and  one  from  general  tuberculosis.  Subsequent  amputation 
was  performed  in  6  cases,  owing  to  recurrence  of  the  disease.  The  local 
conditions  were  eminently  satisfactory,  in  only  one  instance  was  there  a 
sinus,  the  other  cases  showed  wounds  firmly  healed.  Ankylosis  was  present 
in  all  the  cases  except  two,  and  these  two  showed  no  degree  of  flailty. 

As  regards  the  position  of  the  foot,  it  was  in  every  case  in  such  a  position 
that  the  patient  was  able  to  walk  well.  Any  deformities  present  were  slight. 
One  case  had  a  tendency  to  varus,  in  four  instances  the  foot  had  taken  up 
a  slight  position  of  valgus  ;  there  was  one  example  of  a  moderate  degree  of 
calcaneus.  If  one  realises  that  in  all  cases  the  disease  calling  for  excision 
was  extensive,  these  results  must  be  classed  as  exceedingly  good,  when 
considered  from  the  point  of  view  of  a  thoroughly  serviceable  foot. 

The  shortening,  as  a  result  of  the  excision,  averaged  about  f  inch,  and 
in  no  case  was  it  necessary  to  make  a  uniform  thickening  of  the  sole  of  the 
boot.  In  the  examples  of  valgus  deformity  the  sole  was  raised  upon  the 
inner  side. 

Amputation  in  Ankle-joint  Disease. — In  performing  amputation 
for  extensive  disease  of  the  ankle-joint,  one  must  be  guided  very  largely 
by  the  extent  of  the  disease  and  the  position  of  any  sinuses  which  may  be 
present.  It  is  not  advisable  to  employ  a  method  which  necessitates  the 
retaining  of  any  of  the  osseous  portion  of  the  foot.  There  are  conditions 
under  which  it  may  be  justifiable  to  employ  a  Syme  or  a  Mackenzie  am- 
putation, but  the  foot  must  be  very  carefully  examined  in  order  to  be  sure 
that  there  is  no  possibility  of  the  skin  flap  being  infected  with  tubercle. 
In  the  majority  of  cases  it  is  advisable  to  perform  an  amputation  in  the 
lower  third  of  the  leg. 


TUBERCULOUS  DISEASE  OF  THE  TARSUS 
Etiology 

Tuberculous  disease  may  occur  in  any  bone  or  in  any  joint  of  the  tarsus. 
The  astragalus,  from  its  proximity  to  the  ankle-joint,  is  the  most  common 
bone  to  be  affected,  and  in  point  of  frequency  it  is  followed  by  the  os  calcis. 
Of  the  various  joints  the  mid-tarsal  is  the  most  often  diseased.  It  is  rare 
for  the  tarsal  joints  to  become  primarily  infected,  the  disease  is  usually  an 
extension  from  a  neighbouring  tarsal  bone  or  from  the  ankle-joint.  The 
bones  may  be  primarily  infected  quite  apart  from  disease  in  any  other 


TUBERCULOUS  DISEASE  OF  THE  TAESUS  291 

situation,  and  attention  has  elsewhere  been  drawn  to  what  apparently  is 
the  essential  feature  in  the  localisation.  The  occurrence  of  a  primary 
disease  appears  to  depend  upon  a  primary  tuberculous  endarteritis  of  the 
nutrient  vessel  supplying  the  interior  of  the  bone,  a  secondary  degeneration 
of  the  marrow  within  the  bone,  and  a  subsequent  infection  of  the  bone  with 
the  actual  tuberculous  material. 


Pathology 

Anatomy  of  Joint. — The  tarsus  consists  of  seven  bones — the  astragalus, 
OS  calcis,  scaphoid,  three  cuneiforms,  and  the  cuboid.  The  cuneiforms 
articidate  with  the  three  inner  metatarsals  and  the  cuboid  with  the  two  outer. 
Between  the  individual  bones  there  are  six  distinct  synovial  membranes. 
Between  the  astragalus  and  the  os  calcis  there  are  two  distinct  synovial  sacs, 
an  anterior  and  a  posterior,  subdivided  by  the  interosseous  ligament.  The 
anterior  division  communicates  with  the  joint  between  the  astragalus  and 
scaphoid.  There  are  synovial  membranes  which  may  be  designated,  cal- 
caneo-cuboid,  cubo-metatarsal,  cuneo-metatarsal,  and  anterior-tarsal,  the 
names  are  sufficient  explanation  of  their  positions.  The  anterior  tarsal 
joint  is  the  largest  and  the  most  important,  it  passes  between  the  scaphoid 
cuboid,  cuneiforms,  and  the  bases  of  the  second  and  third  metatarsals. 

Patholog'y. — When  the  joints  are  infected  the  pathological  changes  are 
similar  to  those  described  under  the  headings  of  other  situations,  and  the  same 
may  be  said  of  the  bones.  Tuberculous  disease  in  the  tarsal  bones  usually 
extends  rapidly,  because  the  interior  is  predisposed  to  infection  by  the  marrow 
changes.  The  astragalus  and  the  os  calcis  are  the  bones  most  commonly 
afEected,  the  astragalus  on  accoimt  of  its  proximity  to  the  ankle-joint  and  the 
OS  calcis  on  account  of  its  epiphyseal  line,  and  the  strain  which  it  undergoes 
in  supporting  the  body  weight.  The  rule  that  tuberculous  disease  appears 
in  those  parts  which  are  most  liable  to  pressure,  holds  good  in  application 
to  the  other  tarsal  bones.  It  is  more  especially  the  inner  portion  of  the 
tarsus,  the  articulation  of  the  scaphoid  and  cuneiforms,  and  the  astragalo- 
scaphoid  joint,  which  become  diseased. 

Clinical  Features 

The  clinical  features  are  very  similar  to  those  of  ankle-joint  disease, 
and,  therefore,  only  distinguishing  features  will  be  mentioned. 

Pain. — Pain  is  an  early  symptom,  but  it  is  not  so  marked  as  when  the 
ankle  is  involved.  This  is  to  be  expected,  because  the  ankle  is  much  more 
]ia])l('  to  extensive  individual  movements  than  the  nuiltiplicity  of  small 
joints  in  the  tarsus.  Disease  entu'ely  confined  to  the  interior  of  a  tarsal  bono 
may  be  unaccompanied  by  pain. 

Limp  and  Position.  -  -The  character  of  tlie  liinj)  and  the  position  of  the 
foot  at  rest  are  very  similar  to  those  of  the  higher  disease. 

Swelling. — The  swelling  is  distinctive,  it  occurs  at  a  level  below  that  of 

19  a 


292  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

the  ankle-joint,  and  during  the  early  stages  of  the  disease  it  is  confined  to 
the  dorsum  of  the  foot. 

Movements. — Alteration  in  the  movements  of  the  foot  are  important. 
If  the  disease  is  in  any  degree  extensive  the  movements  of  abduction  and 
adduction,  inversion  and  eversion,  are  limited  or  abolished.  An  X-ray 
examination  of  the  part  will  decide  the  exact  localisation  of  the  disease  and 
its  extent. 

Diagnosis 

The  question  of  diagnosis  really  circulates  around  the  point,  whether 
the  disease  is  in  the  ankle-joint  or  in  the  tarsus.  The  situation  of  the 
swelling  and  the  alteration  in  the  various  movements  are  the  points  upon 
which  a  distinction  is  usually  made.  The  information  afforded  by  X-ray 
examination  will  clear  up  any  remaining  doubt. 

Treatment 

The  conservative  methods  of  treatment  are  exactly  similar  to  those 
employed  in  disease  of  the  ankle-joint,  but  operative  measures  remain  to  be 
discussed.  The  operative  measures  which  may  become  necessary  are  as 
follows  : 

1.  Operation  for  disease  of  the  tarso-metatarsal  joints. 

2.  Complete  anterior  tarsectomy. 

3.  Operation  for  disease  of  the  os  calcis. 

4.  Operation  for  disease  of  the  astragalus. 

5.  Posterior  tarsectomy. 

6.  Mikulicz's  osteoplastic  resection. 

Operation  for  Disease  of  the  Tarso-metatarsal  Joints.—  Satis- 
factory operation  in  this  region  is  difficult  on  account  of  the  multiplicity 
and  intercommunication  of  the  various  joints.  At  the  tarso-metatarsal 
articulation  there  are  three  synovial  sacs,  between  the  first  metatarsal  and 
the  internal  cuneiform,  between  the  second  and  third  metatarsals,  and  the 
middle  and  external  cuneiforms,  communicating  with  the  joint  between 
scaphoid  and  cuneiforms,  and  between  the  fourth  and  fifth  metatarsals  and 
the  cuboid.  These  three  joints  are  exposed  and  their  articular  surfaces 
removed  through  different  incisions.  The  internal  joint,  between  internal 
cuneiform  and  first  metatarsal  is  entered  by  an  incision,  which  runs  along  the 
inner  side  of  the  long  extensor  tendon.  The  tendon  is  retracted  outwards, 
and  the  tibialis  anticus  separated  from  its  insertion  into  the  internal  cunei- 
form. The  base  of  the  metatarsal  and  the  articular  surface  of  the  internal 
cuneiform  are  chiselled  across  and  the  intervening  part  removed,  after 
dividing  the  anterior  attachment  of  the  peroneus  longus.  The  joint  between 
the  two  outer  metatarsals  and  the  cuboid  is  exposed  by  an  incision  which  runs 
from  the  peroneal  tubercle  forwards  to  beyond  the  tip  of  the  fifth  metatarsal 


TUBERCULOUS  DISEASE  OF  THE  TARSUS 


293 


bone.  The  tendons  of  the  peroneus  brevis  and  tertius  are  separated  from 
their  insertions,  and  the  sheath  of  the  peroneus  longus  is  opened  and  the 
tendon  retracted.  The  necessary  portion  of  the  fourth  and  fifth  metatarsals 
and  the  cuboid  are  removed.  The  middle  joint  is  reached  by  an  incision, 
which  runs  along  the  centre  of  the  dorsum  of  the  foot.  The  tendons  of  the 
extensor  longus  and  brevis  are  separated  in  the  interval  between  the  second 
and  third  metatarsals.  The  metatarsal  and  tarsal  arteries  are  divided 
between  ligatures.  The  surfaces  of  metatarsals  and  cuneiforms  are  removed, 
the  attachment  of  the  tibialis  posticus  being  separated,  but  it  must  be 
remembered  that  the  synovial  sac  passes  backwards  between  middle  and 
internal  cuneiforms  to  communicate  with  the  joint  between  scaphoid  and 
cuneiforms. 

After-treatment. — After  the  wound  is  healed  the  foot  is  encased  in  plaster 
of  Paris,  and  treated  similarly  to  an  excised  ankle. 

Complete  Anterior  Tarsectomy.— AVhen  the  disease  has  become 
too  extensive  to  permit  of  a  local  removal,  the  operation  of  anterior  tarsec- 
tomy  is  performed.  Two  long 
dorso-lateral  incisions  are  used. 
The  inner  extends  from  the  pos- 
terior third  of  the  first  metatarsal 
backwards  to  the  inner  aspect  of 
the  head  of  the  astragalus.  The 
incision  goes  down  to  the  bone 
except  at  its  posterior  extremity 
where  it  crosses  the  astragalo- 
scaphoid  joint.  The  outer  incision  extends  from  the  posterior  third  of 
the  fifth  metatarsal  to  the  upper  surface  of  the  os  calcis  in  front  of  the 

external  malleolus.  The  dissection  of 
the  inner  incision  necessitates  the  divi- 
sion of  the  attachment  of  the  tibialis 
anticus  to  the  first  metatarsal  and  internal 
cuneiform,  and  the  separation  of  these 
bones  above  and  below.  At  the  outer  side 
the  tendon  of  the  peroneus  tertius  is 
separated  from  its  insertion  into  the  base 
of  the  fifth  metatarsal,  the  tendons  of  the 
peroneus  longus  and  brevis  are  separated 
and  drawn  backwards,  and  the  upper 
and  under  surfaces  of  the  cuboid  and 
outer  metatarsals  are  separated.  The 
separation  is  carried  across  the  dorsum 
of  the  foot,  and  the  dorsalis  pedis 
artery  ligatured  as  it  enters  the  first 
interspace.  The  soft  tissues  are  separated  from  tlie  plantar  asi)ect  of 
the  foot,  and  the  insertions  of  the  tibialis  posticus  divided.  The  diihculty 
of  separating  the  tissues  from  this  concave  surface  is  lessened  by  snipping  off 


Flu.  141. — Incisions  for  excision  of  the  anterior 
tarsus. 


Fio.  142.- 


-Iiicision  for  excision  of  the 
niiil-tursus. 


294 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


Fig.  143. — Incision  for  exxision  of  tlie 
OS  calcis. 


the  base  of  the  fifth  metatarsal  bone.  The  necessary  amount  of  bone  is 
removed  by  using  a  key-hole  saw,  in  front  it  is  carried  through  the  bases  of 
the  metatarsals  ;  behind,  through  the  scaphoid  and  cuboid  or  the  astragalus 
and  OS  calcis.  The  wound  is  drained  by  passing  a  couple  of  large  rubber 
tubes  side  by  side  through  the  wound.  The  after-treatment  consists  in 
keeping  the  foot  at  right  angles  to  the  leg,  and  this  is  most  satisfactorily 
done  by  applying  a  stirrup  splint  to  the  sole  and  lateral  aspects  of  the  limb. 
The  operation  is  necessarily  followed  by  considerable  antero-posterior 
shortening. 

Operation  for  Tuberculous  Disease  of  Os  Calcis. — The  bone  is 
exposed  with  the  least  amount  of  damage  by  a  horseshoe-shaped  incision, 

which  runs  round  the  border  of  the  heel 
from  the  base  of  the  fifth  metatarsal  on 
the  outer  side  to  below  the  internal 
malleolus  on  the  inner  side.  The  soft 
tissues  are  turned  down  in  a  flap, 
carrying  with  them  a  layer  of  cartilage 
from  the  under  surface  of  the  os  calcis. 
This  exposes  the  central  osseous  tissue, 
and  with  a  gouge  and  sharp  spoon 
any  diseased  tissue  is  removed.  The 
cartilaginous  shell  is  left  intact,  and  its 
interior  is  filled  with  some  variety  of  bone  plug,  or  with  simple  blood  clot.' 
The  soft  tissues  are  stitched  back  in  position.  When  the  wound  is  firmly 
healed  and  the  stitches  removed,  the  foot  is  encased  in  plaster  of  Paris  for 
about  three  months.     Full  use  of  the  part  is  then  permitted. 

Operation  for  Tuberculous  Disease  of  the  Astragalus.  —  The 
steps  for  removal  of  this  bone  have 
been  described  in  the  operation  for 
excision  of  the  ankle,  it  is  occasionally 
necessary,  however,  to  remove  the  single 
entire  bone.  This  is  done  by  an  incision, 
which  begins  a  hand-breadth  above  the 
ankle,  at  the  anterior  surface  of  the 
fibula,  and  extends  downwards  to  the 
outer  edge  of  the  peroneus  tertius,  and 
ends  opposite  the  tuberosity  at  the  base 
of  the  fifth  metatarsal  bone.  The 
incision  opens  the  ankle  and  the  astra- 
galo-scaphoid  joints.  The  other  steps 
of  the  operation  are  similar  to  those  described  in  excision  of  the  ankle-joint. 
Posterior  Tarsectomy. — This  operation  has  been  recommended  by 
Kocher  when  disease  involves  the  os  calcis  and  astragalus.  A  long  curved 
incision  is  made  upon  the  outer  surface  of  the  foot,  it  begins  3  inches  above 
the  ankle-joint  at  the  outer  edge  of  the  tendo  achillis,  it  runs  vertically 
downwards  and  turns  forwards  behind  the  external  malleolus  to  end  opposite 


Fig.  141.- 


-lucisiou  for  e.\cisiou  of  the 
astragalus. 


TUBEECULOUS  DISEASE  OF  THE  TAKSUS  295 

the  tuberosity  at  the  base  of  the  fifth  metatarsal.  The  peroneal  tendons 
are  separated  and  pulled  forward.  The  bones  are  removed  sub-periosteally 
if  possible.  The  external  malleolus  is  retained  in  order  to  prevent  forward 
dislocation  of  the  peroneal  tendons.  The  operation  is  not  suitably  em- 
ployed in  children.  As  the  leg  passes  downwards  into  the  defect,  there  is, 
of  necessity,  very  considerable  after  shortening. 

Mikulicz's  Osteoplastic  Resection. — This  operation  is  employed 
as  a  substitute  for  amputation,  when  the  disease  has  extensively  involved 
the  posterior  tarsus  and  is  associated  with  infection  of  the  soft  parts  above 
the  heel.  An  incision  is  made  across  the  sole  of  the  foot  from  the  tuberosity 
of  the  scaphoid  to  the  base  of  the  fifth  metatarsal  bone.  A  second  trans- 
verse incision  is  made  across  the  back  of  the  ankle  between  the  bases  of  the 
two  malleoli.  The  extremities  of  the  incisions  are  joined  by  vertical  incision 
passing  dowm  the  outer  and  inner  sides  of  the  leg  and  foot.  Both  bones  of 
the  leg  are  divided  immediately  above  the  ankle-joint.  The  soft  tissues  are 
divided  from  the  tarsus  dowTiwards  to  beyond  the  disease  and  at  the  distal 
level,  wherever  it  may  be,  the  bones  are  divided.  The  cut  surface  of  tarsus 
or  metatarsus  is  now  approximated  to  the  ends  of  the  leg  bones,  the  long 
axis  of  the  metatarsals  being  in  line  with  that  of  the  leg.  The  wound  is 
closed,  and  the  parts  are  kept  in  position  by  a  posterior  strip  of  aluminium 
bent  to  a  right  angle  opposite  the  metatarso-phalangeal  joint,  in  order  to 
keep  the  phalanges  hyperextended.  When  the  wounds  are  healed  the 
part  is  put  in  plaster  until  there  is  firm  osseous  ankylosis.  After  the  opera- 
tion, as  the  limb  is  lengthened,  a  thick  sole  must  be  applied  to  the  boot  of 
the  opposite  side.  A  specially  designed  boot  must  be  worn  on  the  affected 
limb. 

BIBLIOGRAPHY 

EwALD,  P.     "  Plattfuss  und  Fusswurzeltuberkulose,"   Munch,  vied.  Wochenschr.,  1907,  liv 

2320-2329. 
Broca,  a.     "  Tuberculoso  d'un  ancien  pied  plat,"  Presse  mid.,  Paris,  1907,  xv.  769. 
Walther.      "  Ostc'^oarthrite  tuberculeuse  du  tarse  anterieur,"  BiM.  el  mem.  Soc.  de  Chir. 

de  Paris,  1907,  N.S.,  xx.\iii.  1188. 
Vassalin,  C.  N.     "  Conservative  Treatment  of  Tuberculous  Tibio-tarsal  Arthritis,"  Spilalul 

liucuresci,  1907,  xxvii.  476-492. 
Stioh,   R.     "  f)ber  die   Krfolge   der  operativon   Behandlung  der  Fussgclenkstuberkulose," 

Deutsche  vied.  Wochenschr.,  1908,  xxxiv.  1227-1241. 
Edmunds,  A.     "  Tuberculous  Disease  of  the  Os  Calcis,"  Med.  Press  and  Circ,  London,  1908, 

N.S.  Ixxxv.  401. 
Meyer,  W.     "  Tuberculosis  of  the  Tibio-tarsal  Joint,"  Ann.  Surg.,  1908,  xlvii.  810. 
Lepiiro,  p.     "  Lesions  tuberculeuses  du  cou-dc-pied  et  astragalectomio,"  J.  de  Sc.  mcd. 

de  Lille,  1908,  i.  102-105. 
Reynier.     "  Osteite  tuberculeuse  du  cubitus  gu^rie  par  Ics  bains  et  les  applications  d'oaux 

chlorur^es  sodiques,"  Bull,  et  mem.  Soc.  de  Chir.  de  Paris,  1908,  N-S.,  xxxiv.  600. 
TlxiER.     "  Ost(5oarthrito  tuberculeuse  du  cou-dc-pied,"  Lyon  med.,   1908,  ex.   1398-1402- 
Massabrian  and  Gceit.     "Tuberculoso  du  tarse  anterieur,"  Monlpel.  mid.,  1908,  xxvi. 

494-490. 
Frank,    F.      "  Die   Rcsektion    bei    Fussgelenkstuberkuloso    nach   Bardinhcuer,"  Deutsche 

Zeitschr.  fiir  Chir..  1909,  xcix.  480-523. 
C'haput.     "  Tumour  blanche  du  pied  guerie  ])ar  la  mdthodo  do  Bier,"  Bull,  el  mim.  Soc.  de 

Chir.  de  Paris,  1909,  N.S.,  xxxv.  377. 
Meyer,  W.     "The  Result  of  Bier's  Treatment  in  Tuberculosis  of  the  Tarsus,"  .-Inn.  Surg., 

1909,  i.  639. 


296  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

MuKPEN,  T.  K.  "  Radical  Treatment  of  Tuberculous  Disease  of  the  Tarsus  and  Ankle- 
joint,"  B.M.J. ,  London,  1910,  ii.  1145-1157. 

Sever,  J.  W.  "Tuberculosis  of  the  Ankle-joint  and  Tarsus,"  J.  Am.  M.  Assoc,  Chicago, 
1910,  Iv.  2128-21.33. 

Edmund-s,  a.  "  Tuberculosis  of  the  Foot,"  Med.  Press  and  Circ,  London,  1910,  N.S,,  Ixxxix. 
471. 

Henri  Bourgeois.  Contribution  h  Vetude  de  la  tarsectomie  anterieure  par  incision  transverse 
dans  Us  cas  de  tuberculose  du  tarse  anterieur,  Lyons,  1911,  43  pp. 


LONG  BONES  OF  HAND     AND  FOOT  297 


TUBERCULOUS  DISEASE  OF  THE   LONG  BONES 
OF  THE   HAND  AND  FOOT 

Tuberculosis  of  the  long  bones  of  the  hand  and  foot  have  certam  char- 
acteristics which  combine  to  give  the  condition  a  special  interest.  A\'liile  it 
does  not  belong  exclusively  to  infancy,  it  is  exceptional  to  find  the  condition 
occurring  in  adult  life.  The  commonest  period  of  incidence  is  during  the  first 
five  years  of  life.  Lexer  ^  has  offered  what  he  believes  to  be  the  explanation 
of  the  peculiar  age  period.  His  view  is  as  follows  :  During  childhood  the 
epiphyses  are  ununited  and  the  bones  are  growing.  This  steady  growth 
is  accompanied  by  a  considerable  degree  of  vascularity  in  the  bones,  and  the 
nutrient  vessels  are  of  larger  calibre  than  the  actual  size  of  the  bone  would 
appear  to  demand.  As  age  increases  and  the  epiphyses  become  united, 
the  demand  for  blood  is  lessened,  and  the  size  of  the  nutrient  vessels 
diminishes.  Lexer  believes  that  the  larger  size  of  the  vessels  in  childhood 
is  responsible  for  the  greater  occurrence  of  disease  at  that  period.  It  is 
interesting  to  note  that  the  disease  is  usually  multiple,  and  not  only  multiple 
but  often  symmetrical.  It  is  common  to  find  it  associated  with  tuberculous 
lesions  of  the  skin,  glands,  or  other  bones,  it  is  distinctly  imusual  to  have  it 
appearing  in  conjunction  with  joint  disease. 

Pathology 

From  the  characteristic  fusiform  thickening  which  the  diseased  bone 
acquires,  the  term  "  spina  ventosa  "  has  been  derived.  The  source  of  the 
term  "  spina  ventosa  "  is  a  curious  one.  The  term  "  spina  "  expresses  the 
idea  of  an  ache  comparable  to  that  produced  by  a  thorn  or  spine  prick  ; 
"  ventosa  "  denotes  the  rounded  uniform  outline  of  the  diseased  bone 
(Vincent).* 

The  primary  change  in  the  pathology  is  an  alteration  in  the  main 
nutrient  vessel  supplying  the  bone.  The  vessel  becomes  infected  with  a 
tuberculous  endarteiitis.  There  is  thickening  of  the  wall  and  gradual 
obliteration  of  the  lumen,  and,  as  a  result  of  the  interference  with  the  blood 
supply,  the  red  marrow  disappears  from  the  interior  of  the  bone  to  become 
niplaccd  by  a  fibro-myxoniatous  tissue.  In  addition  to  the  myxomatous 
degeneration  of  the  marrow,  the  bone  lamelljc  tend  to  become  rarefied  and 
absorbed.  When  a  bone  becomes  in  this  way  predisposed,  an  actual  in- 
fection with  tubercle  may  result ;  the  resistance  of  the  marrow  is  destroyed, 
and  the  vessel  lumen  is  so  narrowed  and  altered  that  arrest  of  circulating 
tuberculous  material  readily  occurs.     Certain  bones  are  more  commonly 

'  Lexer,  Unlersurhungen  uber  Knocheiiarlerien,   1904,  Lexer,  Tuliga,  and  Turk. 
*  Vincent,  Internal.  Encycl.  of  Surgery. 

19* 


298 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


attacked  than  others,  and  this  condition  bears  some  resemblance  to  arterio- 
sclerosis, in  so  far  as  it  usually  affects  the  vessel  at  the  point  when  the 
bifurcation  occurs. 

If  tuberculous  material  becomes  definitely  lodged  in  the  interior  of  the 
bone,  the  pathology  becomes  that  of  an  infiltrating  tuberculosis.  The  interior 
of  the  bone  becomes  filled  with  tuberculous  granulation  tissue,  man}'  of  the 
bone  lamellae  are  absorbed  and  those  which  are  left  become  converted  into 
sequestra.  As  the  disease  spreads  in  the  interior,  the  periosteum  becomes 
thickened  by  the  deposit  of  successive  layers  of  new  bone,  apparently  with 
a  view  to  preventing  eruption  of  the  disease  and  infection  of  the  surrounding 
soft  parts.  If  the  disease  should  extend  beyond  the  limits  of  the  bone, 
it  produces  a  superficial  cold  abscess.  It  is  very  exceptional  for  the 
disease  to  involve  a  neighbouring  joint. 

The  characteristic  fusiform  appearance  of  the  bone  is  of  course  derived 
from  the  deposit  of  new  sub-periosteal  bone  and  not  from  any  true 
expansion  of  the  shaft. 

The  disease  is  more  frequent  in  the  hand  than  in  the  foot,  and  the 
metacarpal  bones  and  phalanges  are  affected  with  equal  frequency.  In  the 
foot  the  metatarsal  bones  are  more  often  involved  than  the  phalanges.  It 
is  interesting  to  note  that  the  metatarsal  bone  of  the  great  toe  is  the  one 
most  frequently  affected  ;  it  has  an  important  role  in  sujjporting  the  foot, 
and  the  result  of  the  strain  is  evidenced  by  the  liability  of  its  nutrient  artery 
to  suffer  from  tuberculous  endarteritis. 


Symptoms  and  Physical  Signs 

The  uniform  thickening  of  the  bone  is  usually  the  first  sign  to  arouse 

attention,  the  enlargement 
may  be  accompanied  by 
attacks  of  dull  aching  pain. 
The  overlying  skin  is  at 
first  healthy,  but  as  the 
swelling  increases  it  becomes 
thin,  glossy,  and  purple  in 
colour.  It  eventually  gives 
way,  and  tuberculous  pus  or 
granulation  tissue  escapes. 
^^^^^^^^^^  ^^     The  surface  eruption  of  the 

^  ^^^^^^^^^^3''^^^hI     disease      in  the  case  of  the 

Hjj^^  ^^^^^^^^^^^^I^^H^  always  upon  the 

i^^^^  ^HI^^^H^^^I^^^^^I     lateral  aspect  of  the  bones, 

in    the    case   of   the   meta- 
carpals and  metatarsals  upon 
the  dorsal  aspect  of  the  hand 
or  foot.      The  superficial  sinus  leads  into  soft  carious  bone.     It  is  connnon 
to  find  sequestra  of  quite  considerable  size. 


Fig. 


145. — Multiple  tuberculous  dactylitis.      The  ilisease 
has  progressed  to  abscess  and  sinus  formation. 


PLATE  XLVI. 

</,,  Tuberculous  dactylitis  .ilfectiug  tlic  proximal  phalanx  of  the  finger;  the  interior  of  tin/  jilialaux  is  occupied  by 
-  tuberculous  granulation  tissue,     h.  Tuberculous  dactylitis  of  a  phalanx. 


LONG  BONES  OF  HAND  AND  FOOT 


299 


Before  the  period  of  ulceration,  the  swelling  may  gradually  recede  and 
a  spontaneous  cure  result.  After  the  disease  perforates  the  skin  the  discharge 
of  debris  and  sequestra  continues 
for  some  time,  and  in  favourable 
cases  ultimately  ceases,  the  cica- 
trix becoming  adherent  to  the 
bone.  In  the  severer  cases  cure 
is  only  obtained  at  the  expense 
of  deformity  in  the  shape  of  a 
shortening  of  the  finger  or  toe 
in  its  long  axis.  Sometimes  the 
shortening  is  accompanied  by  a 
lateral  deviation  or  even  by  a 
rotation.  Rarely  the  osseous 
disease  produces  an  irritation  in 
the  neighbourhood  of  the  epi- 
physeal cartilage,  and  an  ex- 
aggerated increase  in  length  of 
the  corresponding  bone  is  pro- 
duced. An  X-ray  examination 
will  show  the  {presence  of  central  i'' 
tuberculous  disease  with  cyst- 
like cavity  formation  and  a  deposit  of  new  sub-])eriosteal  bone.  One 
occasionally  finds  secondary  tuberculous  disease  of  the  epitrochlear  glands. 


146. — Comparative  shorteuiiig  of  finger  as  a  result 
of  tulierculous  disease  of  tlie  metacarpal. 


Syphilitic   Dactylitis. 


Diagnosis 

It  may  be  difficult  to  differentiate  between 
tuberculous  and  specific 
dactylitis.  In  the  latter 
instance  a  central  gum- 
matous formation  or  a 
syphilitic  periostitis  may 
give  an  appearance  to  the 
bone  which  closely  simul- 
ates tuberculous  disease. 
Syphilis  can  be  excluded 
by  the  X-ray  appearances. 
Syphilis  shows  either  a  true 
erosion  of  the  bone  by  a 
central  guninui,  or  dense 
thick  [)eri().stcal  bone  with 
a  dense  interior.  Syphilis 
can  also  be  excluded  by 
the  evidences  of  congenital 
syphilisinotherpartsof  the  body  and  by  the  resultsof  anti-syphilitic  treatment. 


Flu.  147. — Tiiljerculoiis  disease  iill'ectiiig  tl 
and  the  inetacarpals. 


phalanges 


300 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


Tumour  Formation. — Central  tumour  formation,  usually  an  enchon- 
droma,  is  associated  with  a  fusiform  enlargement  of  the  bone.     An  X-ray 


Fig.  148. — Healed  tuberculous  disease  of  the  metacarpal  with  resultiug  shortening  of  the  finger.    • 

photograph  at  once  demonstrates  the  nature  of  the  condition,  for,  in  this 
instance,  the  compact  bone  is  stretched  over  the  central  tumour  into  a  thin 
shell-like  layer. 

Prognosis 

These  are  among  the  more  hopeful  forms  of  tuberculosis,  they  readily 
undergo  spontaneous  cure.  The  accompaniment  of  epitrochlear,  axillary  or 
groin  glandular  disease  increases  the  gravity  of  the  ultimate  outlook.  So 
also  does  a  multiplicity  of  the  disease.  It  is  well  to  warn  the  patient  that 
an  ultimate  cure  may  be  obtained  at  -the  expense  of  a  deformed  and 
shortened  finger  or  toe. 


Treatment 


Conservative  Means.- 


It  is  easy  to  secure  entire  rest  of  the  hand. 
A  most  efficient  and 
serviceable  plan  is  to 
use  a  flat  piece  of  alu- 
minium as  a  splint,  it 
is  neatly  covered  with 

Fig.  149. — Aluminium  splint  applied  for  tuberculous  disease  of     boracic     lint,     adjusted 
the  metacarpals.  ,        j  i  i  p 

to   the   palmar  surface 
of  the  hand,  and  securely  fixed  in  position  with  strips  of  adhesive  plaster. 


LONG  BONES  OF  HAND  AND  FOOT 


301 


The  part  is  powdered  with  talc  and  French  chalk,  and  strips  of  lint  are  laid 
between  the  fingers  to  prevent  excoriation.  This  method  possesses  many 
obvious  advantages.  Other  appliances  have  been  recommended,  such  as 
plaster  of  Paris  and  various  types  of  mechanical  splints.  The  hand  is 
carried  in  the  splint  for  at  least  twelve  months. 

When  the  foot  is  to  be  dealt  with,  nothing  can  be  better  than  a  splint 
made  of  plaster  of  Paris,  it  extends  from  the  middle  of  the  leg  either  up  to 
or  including  the  toes,  according  to  the  situation  of  the  disease.  If  there  are 
objections  to  a  plaster  case,  Jones's  crab  splint  may  be  used,  but  it  does  not 
control  the  toes.  Lately,  one  has  been  using  celluloid  splints  modelled  upon  a 
cast  of  the  foot ;  apart  from  the  difficulty  in  construction,  they  are  excellent. 

During  the  period  of  fixation  the  patient  must  not  bear  any  weight  upon 
the  foot,  if  he  decides  to  go  about,  it  must  be  with  the  aid  of  a  Thomas  knee 
splint.  At  the  termination  of  the  period  of  fixation,  when  the  local  splint, 
whatever  it  may  be,  is  removed,  the  use  of  the  knee  splint  is  persevered  in 
for  some  months  until  there  is  no  possibility  of  recurrence  of  the  disease. 

Operative  Treatment. — There  are  two  possibilities  to  be  considered 
under  this  heading,  they  are  sub-periosteal  resection  or  ciuretting  of  the 
diseased  bone  and  amputation. 

Sub-periosteal  Resection.  Indications. — There  may  be  said  to  be  two 
indications  necessitating  local  removal  of  the  bone,  cold  abscess  formation 
and  sinus  formation.  Cold  abscess  formation  does  not  in  itself  justify  the 
operation,  but,  if,  after  repeated  aspiration  and  proper  conservative  treat- 
ment, the  abscess  recurs,  and  if  the  overlying  skin  is  becoming  thin  and 
devitalised  it  is  advisable  to  step  in  and  remove  the  disease.  Persistent 
sinus  formation  probably  indicates  the  presence  of  a  sequestrum. 

Operation. — A  complete  sub-periosteal  resection  may  be  done,  or  the 
interior  of  the  bone  may  be  thoroughly  scraped  out.  The  second  operation 
is  preferable  to  the  first,  because  in  resecting 
such  small  bones  as  those  of  the  hands  and  feet 
it  is  impossible  to  avoid  serious  damage  to  the 
epiphysis. 

Metatarsals  and  Metacarpals. — To  expose 
the  metatarsals  or  metacarpals  a  straight 
incision  is  made  over  the  dorsum  of  the  hand 
or  foot  along  the  line  of  the  diseased  bone. 
The  extensor  tendons  are  drawn  aside.  The 
periosteum  is  divided  along  the  dorsum  of  the 
bone,  and  separated  all  round  with  the  inter- 
osseous muscles.  If  complete  resection  is  to 
be  attempted  tlie  bone  is  divided  at  the  junction 
of  the  shaft  witli  the  epipliyseal  cartilage,  the 
divided  extremity  of  the  shaft  is  hooked  up 
and  the  peiiosteum  separated  from  tlie  bone 
proximaily,  as  far  beyond  the  disease  as  is  necessary.  Tlie  bone  is  divided 
witli  bone-forceps,  if  possible,  without  opening  into  the  joint.     The  peri- 


FiH.  LIO. — Incisions  for  excision  of 
tlie  nn'tacarpiils  and  I  lie  pliiilmigcs. 


302  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

osteum  is  brought  back  into  position  and  sutured,  and  the  soft  parts  are 
united.  If  curetting  is  j)roposed  in  preference  to  resection  the  bone  is 
opened  with  a  gouge  on  its  dorsal  surface,  or  if  a  sinus  is  present  this  is 
widened.  The  interior  of  the  bone  is  thoroughly  curetted,  the  cavity  is 
rubbed  with  an  antiseptic  paste,  and  the  soft  parts  brought  together. 

Special  mention  must  be  made  of  the  operation  for  disease  of  the  first 
metacarpal  bone.  The  incision  to  expose  the  bone  is  made  along  the  radial 
side  of  the  tendon  of  the  extensor  primi-internodii  pollicis.  The  periosteum 
is  divided  between  the  origin  of  the  abductor  brevis  pollicis  and  the  abductor 
indicis  (first  dorsal  interosseous)  ;  the  periosteum  is  separated  from  the  bone. 
The  bone  is  divided  near  the  epiphysis  at  its  proximal  end.  Any  adherent 
periosteum  is  separated,  and  the  neck  of  the  bone  cut  across  at  its  distal 
extremity. 

After-treatment. — The  hand  and  wrist  are  kept  quiet  for  a  considerable 
time  upon  an  anterior  aluminium  splint  such  as  has  been  described.  In  the 
case  of  the  foot,  as  soon  as  the  wounds  are  healed,  the  part  is  encased  in 
plaster  of  Paris  for  about  six  months. 

Phalanges. — The  phalanges  of  the  hand  are  exposed  through  lateral 
incisions,  which  run  on  each  side  between  the  extensor  tendon  and  the 
digital  vessels  and  nerves.  The  periosteum  is  separated  from  the  dorsal 
and  from  the  palmar  surfaces.  The  distal  end  of  the  bone  is  divided  at 
the  neck,  and  the  shaft  separated  upwards  towards  its  proximal  extremity, 
it  is  then  wrenched  from  its  epiphysis.  In  dealing  with  disease  of  the  first 
phalanx  of  the  great  toe  a  single  lateral  incision  upon  the  inner  side  of  the 
extensor  tendon  is  preferable  to  a  double  incision.  After  removal  of  the 
bone  the  periosteum  is  united  to  the  tendinous  expansion  at  the  side  of  the 
extensor  tendon  with  cat-gut  sutures. 

After-treatment. — The  after-treatment  is  similar  to  that  employed  in 
disease  of  the  metacarpals  and  metatarsals.  The  fingers  are  fastened  to 
an  anterior  splint,  preferably  with  extension,  to  prevent  shortening.  In 
the  foot  it  is  impossible  to  apply  extension,  and  the  part  is  encased  in  plaster 
of  Paris. 

Amputation. — Amputation  is  usually  reserved  for  disease  of  the  phalanges 
of  the  toes.  The  mutilation  is  concealed,  and  conservative  treatment  is 
unsatisfactory  on  account  of  the  difficulty  in  keeping  the  parts  at  rest. 
Every  eSort  should  be  made  to  avoid  amputation  of  the  fingers. 


BIBLIOGRAPHY 

BnDDE.     "  Zur  Frage  dor  ausgeclehnten  Resektionen  am  Tarsus  und  Metatarsus,"  Deutsche 

Zeitschr.  filr  Chir.,  Leipzig,  1907,  xc.  .OVS-GOS. 
Stbinman.     "  Spina  Ventosa,"  Corr.-Bl.  f.  Schweiz.  Arzle,  Basle,  1907,  xxxviii.  23. 
Heineckb,  F.  K.     Beitrage  zur  Behandlmuj  der  Spina  ventosa  mittels  freier  Avtoplastik,  Berlin, 

1908,  G.  Shade. 
LozANO,  P.     "  Osteo-artritis  tuberculosa  en  los  ninos,"  Rev.  Ibero  am.  de  cien.  med.,  Madrid, 

1908,  XX.  94-96. 
RoEPKER,    0.     "  Handgelenktuberkulose,   Trauma   durch   Hoben   eines   Puffers,"   Zeitschr. 

f.  Balm-  u.  Bahnkassendrzte,  1908,  iii.  249-251. 


PLATK    .\I.\II.    -THK    XHAY    AI'I'KAHANl  E    OK    TUBBRCULOrS    Uai'TVI.ITIS. 

There  is  tubciTiilons  iliseasi;  of  tln'  iiii'tiu'iii|i:il  bone  of  tin'  tlnnnl)  with  central  cavity  formation. 


LONG  BONES  OF  HAND  AND  FOOT  303 

Pels  Letjsden.     "  Uber  die   BehancUung  der  Spina  ventosa   raittels  freier  Autoplastik, 

zngleich  ein  Beitrag  zum  Knochentransforinationsgesetz,"  Charite-Aniial.,  Berlin,  1908, 

xxxii.  345-359. 
KuzinN,  Y.  U.     "  Tuberculosis  of  the  Metacarpal  and  Phalangeal  Bones,  their  Peculiarities 

and  Treatment,"  Khirurgia,  Moskow,  1910,  xxviii.  795-821. 
Bailleui,,  Loins.     Des  osteites  tuberculeuses  des  petits  os  longs  de  la  main  et  du  pied  {Spina 

ventosa)  et  des  deforiniles,  etc.,  Paris,  1911,  G.  Steinhut,  296  pages,  8vo. 
Makie.     "  Lesions  osseuses  des  petits  os  de  la  main  et  du  pied,"  Gaz.  hebd.  des  sc.  vied,  de 

Bordeaux,  1913,  xxxiv.  283. 
Green,  R.  M.     "Tuberculous  Osteomyelitis  of  the  Digits,"  Boslon  M.  and  Surg.  J.,  1913, 

clxx.  797-801. 


304  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


TUBERCULOUS  DISEASE   OF  THE   SHOULDER-JOINT 

Etiology 

Tuberculous  disease  of  the  shoulder- joint  is  rare  in  childhood.  Among 
the  cases  of  tuberculous  joints  treated  at  the  Edinburgh  Children's  Hospital 
during  the  past  ten  years,  the  occurrence  of  tuberculosis  of  the  shoulder 
has  been  5  per  cent.  It  is  said  that  the  right  shoulder- joint  is  more 
commonly  affected  than  the  left.  One  thing  is  certainly  evident,  this  form 
of  tuberculous  disease  is  frequently  accompanied  by  tuberculosis  in  other 
regions. 

Pathology 

Anatomy  of  Joint. — In  order  properly  to  imderstand  the  distribution 
and  pathology  of  the  disease  it  is  essential  that  certain  points  in  the  anatomy 
of  the  joint  be  made  clear.  The  shoulder- joint  in  itself  is  a  shallow  and 
simple  joint,  but  it  has  three  prolongations  which  increase  its  complexity ^- 
one  corresponding  with  the  long  head  of  the  biceps,  one  with  the  tendon  of 
the  subscapularis,  and  a  third  wath  the  tendon  of  the  infraspinatus.  The 
distribution  of  infection  and  the  position  of  superficial  abscess  formation  is 
largely  determined  by  the  position  of  these  diverticula. 

Patholog"ical  Anatomy. — It  is  usually  stated  that  the  primary  focus 
of  disease  is  an  osseous  one,  and  that  the  joint  is  infected  secondarily. 
Gangolphe  ^  has  lately  published  investigations  of  32  cases.  Osseous  disease 
was  present  in  29  instances,  and  in  nearly  every  case  the  epiphysis  was  the 
site  of  the  disease.  The  tuberculous  process  in  the  bone  may  be  an  infiltrat- 
ing or  an  encysted  type.  Volkmann  -  has  described  an  atrophic  non- 
suppurating  variety  to  which  he  has  applied  the  term  caries  sicca  and 
which  he  considers  is  almost  entirely  confined  to  this  locality.  It  is  char- 
acterised by  the  formation  within  the  joint  of  a  quantity  of  granulation  tissue 
which  is  peculiarly  dry  and  fibrous  in  type.  The  cancellous  tissue  in  the  head 
of  the  humerus  is  replaced  by  fibro-myxomatous  tissue  and  the  bone  lamellae 
become  wasted  and  rarefied.  The  joint  ligaments  share  in  the  general  fibrous 
metaplasia  and  they  begin  to  contract.  As  the)'  contract  they  gradually 
pull  the  head  of  the  humerus  closer  against  the  wall  of  the  glenoid  fossa. 
The  increased  pressure  upon  the  diseased  bone  leads  to  an  atrophy,  and 
ultimately  to  a  complete  disappearance  of  the  humeral  head.  This  is  the 
sequence  of  events  which  Volkmann  described. 

1  Gangolphe,  Arlhriles  iuberculeuses  (1906),  p.  9. 
^  Volkmann,  Samml.  f.  Hi7i.  Vorlrdge,  1879. 


'J:       — 


Oh 


TUBERCULOUS  DISEASE  OF  SHOULDER-JOINT 


305 


Konig  ^  has  detailed  another  variety  of  tuberculous  disease  of  the 
shoulder,  which  he  considers  is  practically  confined  to  this  region.  It  has 
been  given  the  name  caries  carnosa.  The  tuberculous  granulation  tissue  in 
the  joint  is  vascular  and  proliferating,  and  the  inter- lamellar  spaces  of  the  bone 
are  filled  with  fleshy-Hke  granulation  tissue,  which  microscopically  is  shown 
to  be  a  vascular  granulation  tissue  with  tubercles  intermingled  ;  the  frame- 
work of  the  bone  is  considerably  rarefied.  It  has  been  suggested,  and  there 
is  considerable  ground  for  the  supposition,  that  caries  sicca  and  caries  carnosa 


Flu.  151. — Tuberculous  ilisease  of  the  right  shouhlur-joiut  with  sinus  Ibrmiition. 

are  but  stages  iu  the  same  variety  of  tuberculosis.  Caries  sicca  follows 
caries  carnosa  by  reason  of  a  fibrous  metaplasia  in  the  vascular  granulation 
tissue. 


Symptoms  and  Physical  Signs 

Symptoms.  'I'lio  symptomatology  of  shoulder-joint  tuberculosis  is 
peculiar  for  the  astonishing  insidiousnoss  with  which  the  disease  comes  on. 
There  are  several  factors  responsible  for  this:  (1)  The  joint  is  not  to  any 
extent  a  weight-bearing  one,  and,  therefore,  there  is  not  the  same  tendency 
to  exaggeration  of  .symptoms  which  one  finds  in  the  joints  of  the  lower 
extremity.  (2)  The  scii[)iila  has  great  power  of  mobility  upon  the  thorax, 
'  Konig,  Die  apecielle  Tuberlculose  der  Knochcn  und  Qeleiiken,  1890. 

20 


306  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

and  any  slight  degree  of  fixation  at  the  shoulder- joint  may  be  disguised 
by  this  secondary  movement.  The  symptoms  of  the  disease  may  be  summar- 
ised as  those  of  pain,  tenderness,  restriction  of  movement,  and  muscular 
atrophy. 

Pain. — Pain  is  usually  the  first  symptom  to  appear  or  at  least  to  be 
noticed  by  the  sufferer.  It  is  frequently  traced  to  the  origin  of  a  fall  or  blow 
upon  the  shoulder.  At  first  the  pain  is  only  elicited  when  the  joint  is  moved  ; 
in  a  fully  established  case  it  is  almost  constantly  present.  It  is  characteristic 
that  it  is  complained  of  at  night  when  the  patient  lies  upon  the  affected 
shoulder,  and  so  brings  the  articular  surfaces  into  contact.  The  pain  is' 
complained  of  at  the  front  of  the  joint  and  at  the  insertion  of  the  deltoid. 
It  is  of  a  dull,  aching  character,  and  it  may  be  referred  to  the  elbow  and 
forearm. 

Tenderness. — Tenderness  is  complained  of  upon  all  sides  of  the  joint ; 
it  is  elicited  by  pressure  to  the  outer  side  of  the  coracoid  process,  on  the 
greater  tuberosity,  and  at  the  posterior  margin  of  the  deltoid. 

Rigidity. — There  is  distinct  limitation  of  the  movements  of  the  joint, 
especially  those  accompanied  by  rotation  and  abduction.  Care  must  be 
taken  not  to  mistake  scapular  movements  for  movements  at  the  shoulder- 
joint.  The  patient  cannot  lift  the  arm  from  the  side  bej^ond  a  short  distance, 
and  there  is  considerable  pain  when  he  attempts  to  place  the  hand  behind  his 
back  or  behind  his  head  ;  yet  he  can  without  discomfort  lay  his  hand  upon 
the  opposite  shoulder,  or  push  his  arm  forwards. 

Wasting  and  Position. — Rapid  atrophy  of  the  shoulder  muscles  takes 
place,  and  as  the  wasting  of  the  deltoid  increases,  the  tuberosities  of 
the  humerus  become  more  distinct  and  palpable.  The  limb  takes  up 
faulty  positions  which  may  well  find  a  parallel  to  those  observed  in  hip- 
joint  disease.  At  an  early  period,  the  position  of  the  limb  is  one 
of  slight  abduction ;  later  on,  as  fluid  begins  to  accumulate  in  the  joint, 
the  arm  is  placed  in  a  position  of  abduction,  flexion,  and  some  internal 
rotation.  The  shoulder  tip  is  depressed.  At  a  still  more  advanced  period 
the  arm  is  held  across  the  wall  of  the  chest  in  an  extreme  position  of 
adduction.  The  shoulder  being  raised  there  is  an  impression  of  apparent 
shortening.  Palpation  of  the  joint  will  demonstrate  a  local  increase  of 
temperature,  perhaps  an  increase  of  fluid  in  the  joint,  and  occasionally  an 
actual  enlargement  of  the  bones  forming  the  joint. 

Abscesses. — Peri-articular  abscesses  develop  around  the  joint.  They 
make  their  way  along  the  synovial  prolongations  with  the  subscapularis 
and  infraspinatus,  and  appear  in  the  axilla,  or  they  are  guided  by  the  long 
head  of  the  biceps  and  appear  on  the  front  of  the  joint ;  sometimes  they 
pass  directly  through  weak  places  in  the  capsule  above  and  below  the  sub- 
scapularis. The  part  above  is  really  in  contact  with  the  long  head  of  the 
biceps,  and  by  this  latter  structure  the  pus  is  guided.  Should  the  capsule 
be  perforated  below  the  subscapularis,  the  pus  makes  its  way  beneath  the 
deltoid  muscle  and  points  in  front  of  or  behind  its  insertion.  The  examination 
concludes  with  an  X-ray  photograph  taken  in  an  antero-posterior  direction. 


TUBERCULOUS  DISEASE  OF  SHOULDER-JOINT  307 

Special  Clinical  Features  of  Caries  Sicca. — If  one  is  to  classify 
caries  sicca  as  a  separate  variety  of  tuberculous  shoulder,  it  is  essential  to 
allude  to  certain  clinical  features  which  are  apparently  characteristic  of  the 
disease.  There  are  two  things  which  most  forcibly  strike  one  :  there  is  no 
swelling,  or  if  there  has  been  any  it  rapidly  subsides,  and  there  is  no  abscess 
formation.  The  muscular  wastino;  is  the  most  striking  characteristic.  The 
shoulder  has  the  appearance  of  a  subcoracoid  dislocation,  the  deltoid  is 
so  wasted  that  the  shoulder-joint  seems  unoccupied,  it  is  possible  even  to  see 
beneath  the  coraco-acromial  arch.  The  arm  is  held  close  to  the  side  of  the 
chest,  and  any  attempt  at  movement  is  accompanied  by  great  pain.  Ulti- 
mately there  is  complete  fibrous  ankylosis  of  the  joint  in  this  adducted 
position,  and  probably  a  true  shortening  of  the  bone  in  its  long  axis. 

Diagnosis 

The  actual  diagnosis  is  made  by  the  insidious  onset  of  symptoms,  and 
the  physical  quartette  of  pain,  tenderness,  rigidity,  and  atrophy.  The 
differential  diagnosis  will  necessitate  the  exclusion  of  subdeltoid  bursitis. 
In  bursitis  it  is  the  movement  of  abduction  which  chiefly  elicits  pain,  in 
tuberculosis  all  movements  are  painful.  The  muscular  wasting  in  tubercu- 
losis is  infinitely  greater  than  that  which  may  occur  in  bursitis.  In  cases 
associated  with  marked  wasting  of  the  deltoid  muscle,  the  shoulder  has  an 
appearance  suggestive  of  a  subcoracoid  dislocation,  and  if  the  disease  has 
been  ushered  in  with  a  history  of  traumatism  a  mistake  is  apt  to  be  made 
and  the  case  treated  as  a  true  dislocation. 


Prognosis 

With  complete  cure  of  the  disease  the  best  that  can  be  hoped  for  is 
partial  or  complete  ankylosis  of  the  joint,  but  the  compensating  movement 
of  the  scapula  is  so  good  that  little  inconvenience  may  arise  from  even  a 
com])lete  ankylosis.  The  most  favourable  position  for  ankylosis  is  one  of 
moderate  abduction.  When  the  prognosis  is  considered  from  the  point  of 
viewof  expectation  of  life,  it  should  be  understood  that  tuberculous  affections 
of  the  shoulder  are  iriore  serious  than  a  similar  disease  in  other  joints,  and  the 
explanation  of  this  is  that  a  considerable  proportion  of  them  are  followed  by 
tuberculous  disease  of  the  lung  upon  the  affected  side.  The  death  rate  is 
higher  than  in  disease  of  the  joints  of  the  lower  extremity. 

Treatment 

Conservative  Treatment.  —  The  joint  should  be  fixed  in  such  a 
position  that  in  the  event  of  ankylosis  occurring  the  maximum  amount  of 
use  in  the  ])art  will  be  available.  The  most  advantageous  position  is  one 
of  abduction  to  half  a  right  angle  with  a  slight  degree  of  flexion. 

There  is  a  variety  of  methods  for  fixing  the  joint.     In  children  we  have 


308  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

found  a  modification  of  Middledorpf  "s  splint  most  useful.  A  strip  of  aluminium 
1|  to  2  inches  broad  is  padded  with  boracic  lint.  It  is  moulded  in  such  a 
way  that  it  passes  along  the  inner  side  of  the  upper  arm  from  the  elbow  into 
the  axilla  and  down  the  side  wall  of  the  chest  for  about  6  inches.  The  bend 
is  fitted  to  the  proper  degree  of  abduction.  The  splint  is  fastened  to  the 
arm  and  to  the  chest  wall  with  several  strips  of  adhesive  plaster.  Jones 
and  Ridlon  recommend  the  use  of  a  halter  which  suspends  the  forearm  to 
the  neck  at  a  right  angle.  A  supplementary  band  of  adhesive  strapping 
or  bandage  is  passed  from  the  elbow  round  the  body,  and  the  region  of  the 
shoulder  is  supported  by  imbricated  bands  of  sticking-plaster  which  cross 
the  outer  part  of  the  shoulder  and  over  the  shoulder  girdle.  Plaster  of  Paris 
has  been  recommended  for  use  in  this  region,  but  it  is  exceedingly  difficult 
to  adjust  it  to  the  proper  degree  of  comfort  and  yet  properly  to  fix  the  arm. 
It  is  never  necessary  to  employ  extension,  the  weight  of  the  arm  in  the 
vertical  position  is  sufficient ;  in  fact,  additional  extension  often  aggravates 
the  pain.  Conservative  treatment  must  be  persevered  in  for  at  least 
twelve  months;  the  period  is  of  course  shorter  than  in  weight-bearing  joints. 

Operative  Treatment. — Indications. — There  are  those  who  say  that 
the  possibility  of  lung  infection  following  shoulder  disease  is  so  real  that 
complete  excision  should  be  performed  as  early  as  possible.  And  it  is  further 
urged  that  conservative  treatment  persevered  in  will  probably  result  in 
ankylosis,  whOe  an  early  excision  often  means  a  movable  joint.  These 
are  two  very  potent  reasons  in  favour  of  early  excision.  The  great  majority 
are  agreed  that  operation  should  not  be  delayed,  when  conservative  treat- 
ment is  failing  to  afford  relief,  when  abscess  formation  has  appeared,  and 
when  sinuses  are  present. 

Type  of  Operation. — The  joint  may  be  exposed  by  an  anterior  or  by  a 
posterior  route.  When  the  disease  is  situated  chiefly  in  the  upper  end  of 
the  humerus  the  anterior  method  is  preferable.  When,  however,  the  disease 
is  chiefly  synovial  or  involving  the  glenoid  cavity  the  posterior  route  should 
be  chosen. 

Anterior  Excision. — After  preparation  of  the  part  the  patient  is  placed 
in  such  a  position  that  the  affected  shoulder  projects  beyond  the  edge  of 
the  table.  The  arm  to  the  middle  of  the  upper  arm  is  wrapped  in  a  sterilised 
towel.  These  preliminaries  are  necessary  to  permit  of  movement  of  the  arm 
in  any  direction  during  operation.  The  incision  begins  on  the  clavicle  above 
the  coracoid  process,  and  it  passes  obliquely  downwards  and  outwards  along 
the  anterior  border  of  the  deltoid  muscle.  As  the  incision  is  deepened  the 
cephalic  vein  is  exposed,  running  in  the  interval  between  the  deltoid  and  the 
pectoralis  major.  The  muscles  are  separated,  the  deltoid  is  pulled  out- 
wards, and  the  pectoral,  with  the  vein,  is  pulled  inwards.  To  assist  in  re- 
traction of  the  deltoid  its  anterior  border  is  divided  just  below  its  attachment 
to  the  clavicle.  In  the  retracted  interval  there  are  now  exposed  from  above 
downwards,  the  pectoralis  minor,  the  coraco-brachialis  with  the  short  head  of 
the  biceps,  the  anterior  surface  of  the  neck  of  the  humerus,  and  the  tendon 
of  the  pectoralis  major.     Pressing  one's  finger  on  the  humerus  at  the  outer 


TUBERCULOUS  DISEASE  OF  SHOULDER-JOINT 


309 


Fig.  152. — Incision  for  e.vcision  of  the 
stionMer  by  the  anterior  rontc. 


edge  of  the  coraco-brachialis  and  biceps,  one  feels  the  bicipital  groove  of  the 
humerus,  it  contains  the  long  head  of  the  biceps  lying  in  its  sheath.  The 
sheath  is  slit  up  and  the  biceps  tendon  retracted  inwards.  The  arm  is  now 
rotated  outwards,  and  the  tendon  of  the  subscapularis  exposed  as  it  passes  to 
the  lesser  tuberosity  ;  the  tendon  is  detached  vnth  the  periosteum  and  the 
inner  edge  of  the  capsule.  The  arm  is 
rotated  inwards,  and  from  the  greater 
tuberosity  the  supraspinatus,  infraspinatus, 
and  teres  minor,  with  the  periosteum  and 
the  outer  edge  of  the  capsule,  are  de- 
tached. In  every  instance  the  separation 
is  made  parallel  to  the  bicipital  groove. 
The  incision  which  exposed  the  long  head 
of  the  biceps  opened  the  shoulder-joint, 
and  it  is  extended  slightly  upwards  to  the 
edge  of  the  glenoid  cavity.  By  carrying 
the  arm  downwards  into  a  vertical  position 
over  the  edge  of  the  table  the  head 
of  the  humerus  is  made  to  project  from 
the  joint.  The  disease  is  thoroughly 
eradicated,  and  the  necessary  amount 
of  bone  removed.  On  account  of  the 
extent  of  the  disease  it  may  be  necessary  to  expose  the  humerus  lower  down. 
To  do  this  the  incision  is  enlarged.  Care  must  be  taken  to  avoid  the  anterior 
and  posterior  circumflex  arteries  and  the  circumflex  nerve  ;  the  former  may 
be  ligatured,  the  latter  must  be  kept  intact.  The  section  of  the  head  is 
made  obliquely,  and  as  far  as  possible  parallel  to  the  anatomical  neck.  The 
cut  surface  must  be  made  as  smooth  and  rounded  as  possible,  and  it  is  re- 
commended to  cover  the  raw  surface  with  a  flap  of  soft  parts,  or  with  thin 
sheet  rubber,  gold-foil,  or  membrane.  The  end  of  the  bone  is  returned  within 
the  capsule  and  the  wound  is  closed.  The  separated  muscles  are  restored 
to  the  respective  tuberosities  and  sutured  in  place  with  catgut.  Tlie  long 
head  of  the  biceps  is  replaced  in  the  bicipital  groove,  and  the  sheath 
sutui'ed  over  it.  A  drainage  tube  may  be  inserted  into  the  joint  cavity 
and  brought  out  by  a  stab  puncture  behind  establishing  a  through 
drainage. 

After-lrealmenl. — In  applying  the  dressing  a  pad  should  be  placed  in 
the  axiUa  to  prevent  the  upper  end  of  the  humerus  being  displaced  inwards. 
The  upper  arm  is  fixed  to  tiie  chest  with  a  bandage,  and  the  forearm  is  (Mrried 
in  a  sling.  Care  must  be  taken  that  the  axillary  pad  does  not  exert  too  nuicli 
])ressure  on  the  large  blood-vessels.  The  joint  is  kept  iinmnbilised  for  about 
three  weeks  after  the  operation,  in  order  that  the  muscles  which  have  been 
detached  may  be  firmly  rejoined.  Passive  movements  are  then  begun  and 
gradually  increased.  For  two  niontlis  the  forearm  and  elbow  sliould  be 
supported  with  a  sling,  as  tiie  weight  of  the  unsupported  arm  tends  to  stretch 
and  relax  the  healing  structures.     If  much  bone  has  been  removed  in  the 


310  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

course  of  the  operation,  the  part  should  be  immobilised  for  four  weeks  before 
movements  are  begun. 

Posterior  Excision. — The  patient  is  put  in  a  prone  or  a  semi-prone 
position  with  the  affected  shoulder  raised  and  projecting  over  the  edge  of 
the  table.  The  other  preliminaries  are  similar  to  those  described  in  the 
anterior  operation.  The  skin  incision  begins  at  the  acromio-clavicular  joint, 
it  passes  along  the  upper  border  of  the  acromion  to  the  root  of  the  process, 
and  from  thence  downwards  in  a  curved  direction  to  end  about  1  inch  above 
the  posterior  fold  of  the  axilla.  The  incision  opens  the  acroinio-clavicular 
joint,  it  divides  the  fibres  of  the  trapezius  as  they  are  inserted  along  the  upper 
border  of  the  spine  of  the  scapula,  and  lower  down  it  exposes  the  fibres  of 
the  deltoid  muscle.  A  finger  is  passed  beneath  the  edge  of  the  deltoid 
muscle,  and  its  deep  surface  is  separated  from  the  teres  minor  and  the 
infraspinatus.  The  posterior  fibres  of  the  deltoid  muscle  are  divided. 
The  upper  border  of  the  infraspinatus  is  separated  from  the  lower  border 
of  the  spine  and  the  root  of  the  acromion  process.  The  lower  border  of 
the  supraspinatus  is  detached  from  the  upper  border  of  the  spine.  A 
finger  can  now  be  passed  imderneath  the  acromion  process  from  behind 
forwards.  The  scapular  origin  of  the  deltoid  is  separated  with  the 
periosteum,  or  the  acromion  process  is  chiselled  obliquely  through  at  its 
base,  this  latter  is  more  suitable  in  children.  A  deltoid  flap,  with  or  wi*-hout 
the  acromion  process,  is  turned  outwards  to  expose  the  head  of  the  humerus 
covered  with  the  insertion  of  the  external  rotators,  the  supraspinatus, 
infraspinatus,  and  teres  minor.  In  front  of  the  external  rotators  the 
capsular  ligament  is  exposed,  and  if  the  arm  is  externally  rotated  the  bicipital 
groove,  with  the  long  head  of  the  biceps,  appears  more  anterior.  An  incision 
is  now  made  over  the  head  of  the  humerus  in  the  coronal  direction  ;  it  begins 
at  the  insertion  of  the  capsular  ligament  into  the  humerus,  it  extends  through 
the  capsule  parallel  to  the  anterior  border  of  the  supraspinatus,  and  it 
exposes  the  tendon  of  the  long  head  of  the  biceps  as  far  as  the  edge  of  the 
glenoid  cavity.  The  insertion  of  the  external  rotators  is  separated  from 
the  greater  tuberosity,  and  the  muscles  are  pulled  backwards.  The  tendon 
of  the  biceps  is  held  forwards.  The  head  of  the  humerus  and  the  glenoid 
cavity  are  exposed,  and  if  more  room  is  required  the  subscapularis  is  separated 
upwards  and  inwards  from  the  lesser  tuberosity.  By  adducting  the  arm 
and  pushing  the  elbow  upwards  the  head  is  displaced  through  the  opening  in 
the  capsule.  When  the  disease  has  been  thoroughly  removed  the  parts 
are  restored.  The  external  rotators  are  sutured  in  position,  also  the  sub- 
scapularis if  it  has  been  detached.  The  deltoid  is  stitched  back  to  the  spine, 
or,  if  the  acromion  has  been  divided,  the  bone  surfaces  are  wired.  The 
posterior  fibres  of  the  deltoid  are  united. 

The  after-treatment  is  similar  to  that  employed  in  the  anterior  excision. 

BIBLIOGRAPHY 

Kellock,  T.  H.     "  Excision  of  Joints,  a  New  Method  of  Operating  at  the  Shouldei,"  Tr. 

Clin.  Soc,  London,  1907,  xl.  94-97. 
Morris,  R.  T.     "  Tuberculosis  of  the  Scapula,"  Post  Grad.,  New  York,  1908,  xxiii.  324. 


TUBERCULOUS  DISEASE  OF  SHOULDER- JOINT  311 

ScuDDER,  C.  L.,  and  Bakney,  J.  D.  "  Excision  of  the  Shoulder-joint,"'  Pub.  Mass.  Gen. 
Hasp.,  Boston,  1909,  ii.  446-464. 

GlLETTE,  H.  J.  "  A  Simple  Dressing  for  the  Treatment  of  Tuberculous  Disease  of  the  Shoulder- 
joint,"  Amer.  .Journ.  Orih.  Surg.,  1909-10,  vii.  31-34. 

ScuDDER,  C.  L.,  and  Barney,  .J.  D.     "  Excision  of  the  Shoulder-jnint,"  .4»;.  Surg.,  Phila- 

'       delphia,  1909,  xlix.  696-706. 

DucHAMP.     "  Arthrite  tuberculeuse  de  I'epaule  a  marche  rapide,"  Loire  med.,  St.  Etienne, 

1909,  xxviii.  134. 

ScuDDER.     "  Excision  of  the  Shoulder-joint,"  Boston  Med.  and  Surg.  Journal,  1909,  clx.  549. 
Sever,  J.  W.     "  Tuberculosis  of  the  Shoulder  in  Children,"  Boston  Med.  and  Surg.  Journal 

1910,  elxii.  383-386. 

Zhachenko,  H.  S.     "  Dry  Caries  of  the  Shoulder-joint,"  Sibirsh.  Vrarh  Gaz.,  Irkutsk,  1910, 

iii.  485-497. 
Peraire.     "  Tumeur  blanche  de  Tepaule,  etc.,"  Paris  chirury.,  1910,  ii.  155. 


312  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


TUBERCULOUS  DISEASE   OF  THE   ELBOW-JOINT 

Etiology 

We  have  found  that  the  elbow  ranks  common  among  tuberculous  joints 
in  the  degree  of  occurrence.  It  is  correctly  stated,  but  hitherto  without 
explanation,  that  girls  are  more  commonly  affected  than  boys.  The  first 
ten  years  of  life  is  the  most  usual  period  for  the  disease  to  develop,  and 
in  that  period  slightly  more  than  half  of  the  cases  occur  during  the  first  five 
years. 

Pathology 

Anatomy  of  the  Joint. — The  joint  is  formed  by  the  articulation  of  the 
humerus  above  with  the  ulna  and  radius  below.  The  lower  epiphysis  of  the 
humerus  is  made  up  of  the  articular  surface  of  the  bone  and  the  two  centres 
of  ossification  which  form  it — the  outer  or  capitellar  and  the  inner  or 
trochlear.  Ossification  begins  in  the  capitellar  during  the  second  year  of 
life  ;  it  does  not  begin  in  the  trochlear  until  the  eleventh  year.  Therefore, 
during  the  first  two  years  of  life  the  lower  epiphysis  of  the  humerus  is  entirely 
cartilaginous.  The  upper  epiphysis  of  the  ulna  does  not  form  more  than 
the  tip  of  the  olecranon,  and  it  remains  cartilaginous  until  the  tenth  year. 
The  upper  epiphysis  of  the  radius  is  a  rounded  disc  upon  the  end  of  the  bone, 
ossifying  about  the  sixth  year.  The  synovial  membrane  extends  upwards 
upon  the  humerus  for  some  distance  beyond  the  epiphyseal  cartilage;  vessels, 
therefore,  entering  the  bone  from  the  synovial  reflexion  pass  into  the  meta- 
physis  of  the  bone.  The  synovial  membrane  is  not  reflexed  to  any  extent 
upon  the  ulna,  but  the  neck  of  the  radius  is  surrounded  by  a  ditch-like 
prolongation  to  which  the  term  "  recessus  sacciformis  "  has  been  applied. 

Pathological  Anatomy. — Situation  of  the  Disease. — The  disease  may 
begin  in  the  synovial  membrane  or  in  the  bones  forming  the  joint.  Probably 
about  25  per  cent  are  primarily  synovial.  Of  the  various  bones  the  humerus 
is  most  frequently  diseased,  and  the  ulna  is  more  liable  to  infection  than  the 
radius.  The  disease  in  the  humerus  is  primarily  situated  in  the  metaphysis, 
and  if  the  epiphysis  should  be  diseased  the  infection  is  secondary  to  the 
metaphyseal  disease  or  to  disease  in  the  joint.  In  the  ulna  the  focus  appears 
in  the  region  of  the  lesser  sigmoid  cavity,  and  in  the  radius  about  the  neck. 
These  various  situations  of  disease  are  determined  by  the  position  in  which 
vessels  from  the  synovial  reflexion  enter  the  bone.  The  more  detailed 
pathology  of  membrane  and  bone  is  similar  to  that  already  described  (see 
page  35). 


rL.VI'K    .\l,l.\.- 


-'I'HK    I'ATllOUKiV    (IK    'I'niKIU  ULOUS    DlSl.ASK    OV   'llIK    El.UDW-JolXT. 


a  Disunsc  u(  Dk  svnoviul  iiHMnliniiif  in  tlic  "  recessiis  sftcciformis "  aiwind  llio  neck  of  the  ra.lius. 
/.  TiibiTculous  .synoviui  iiK-iriliniiie  in  Hit-  olciauon  iukI  coronoiil  fnsMie  of  tlie  laiineins.  r,  lulicrcn  ous 
synovial  .liscxse  u.onna  the-  lowt-r  ™,1  of  tlu'  Iiun.uius.  ,/,  TuliL-irnlons  svnovnil  nui.il.ian,-  Miin.nn.luig 
I  ho  iip|..r  cii.l  ..r  tin-  rmlina.  <•,  Tulwivnlmis  .liswise  of  tile  .synovial  nieml.ianL-  aroiuul  the  lovvur  end  ol 
till'  luniurus :  tlie  iliwase  is  beginning  to  invuile  the  interior  of  the  bone. 


TUBERCULOUS  DISEASE  OF  ELBOW-JOINT 


313 


Symptoms  and  Physical  Signs 

Symptoms. — The  leading  features  in  the  disease  are  those  of  pain, 
tenderness,  swelling,  stiffness,  deformity,  and  muscular  wasting. 

Pain. — Pain  is  usually  an  early  featiire  of  the  disease,  it  is  localised  to  the 
joint,  and  it  is  increased  by  movements  of  the  joint.  In  late  stages  of  the 
disease,  when  there  is  a  considerable  degree  of  soft  tissue  involvement,  a 
neuritis  of  the  ulnar  nerve  may  be  responsible  for  tingling  and  numbness 
along  the  inner  side  of  the  forearm. 

Tenderness. — There  is  local  tenderness  to  pressure,  especially  over  the 
seat  of  the  disease.  The  first  situation  to  show  tenderness  is  the  space  upon 
each  side  of  the  olecranon.     The  local  temperature  is  often  raised. 

Swelling. — The  swelling  comes  on  gradually.  If  it  is  the  result  of  a 
synovial  thickening  it  first  becomes  evident  in  that  region  in  which  the 
synovial  membrane  is  most 
superficial,  namely,  around 
the  olecranon  and  in  the 
space  between  the  head  of 
the  radius  and  the  external 
condyle  of  the  humerus. 
The  swollen  regions  have 
the  characteristic  doughy 
and  elastic  feeling ;  at  any 
moment  the  swelling  may 
be  increased  by  an  effusion 
into  the  joint.  As  the  dis- 
ease progresses  the  swell- 
ing ceases  to  be  limited  by 
the  distribution  of  the  syn- 
ovial membrane,  and  it  be- 
comes more  general.  The  soft  parts  around  become  involved,  and  the  joint 
acquires  the  characteristic  spindle  shape.  It  is  often  possible  to  appreciate 
a  thickening  of  the  bone,  for  example  the  lower  part  of  the  shaft  of  the 
humerus. 

Stiffness. — Probably  the  most  important  physical  sign  is  the  restriction 
of  movement  in  the  joint.  It  is  the  result  of  the  characteristic  muscular 
spasm  which  becomes  evident  when  the  limit  of  painless  motion  is  reached. 
At  first  only  the  extremes  of  flexion  and  extension  are  interfered  with,  but 
the  movements  gradually  become  less  until  the  joint  is  fixed  in  a  jjosition 
midway  between  flexion  and  extension,  with  the  forearm  midway  between 
pronation  and  supination.  In  an  osseous  lesion  pronation  and  supination 
remain  perfect  for  some  time  after  flexion  and  extetision  arc  limited  ;  in 
synovial  di.sease  all  movements  are  equally  interfered  with. 

Deformity. — The  characteristic  deformities  of  the  disease  are  those  of  a 
fusiform  swelling  with  the  elbow  held  at  about  ii  right  angle,  and  the  forearm 
midway  between  pronation  and  supination. 

20  * 


Fig.  153. — Advauced  disease  of  the  elbow-joiut  and  lower 
end  of  humerus. 


314  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

Atrophy. — There  is  a  marked  atrophy  of  the  muscles  of  the  upper  arm. 
Those  of  the  forearm  are  not  so  markedly  affected,  as  they  are  kept  in  con- 
dition by  the  movements  of  the  wrist-joint.  The  examination  must  include 
the  taking  of  an  X-ray  photograph  ;  this  should  be  done  in  two  directions, 
antero-posterior  and  lateral.  By  this  manoeuvre  the  exact  situation  of  the 
disease  is  demonstrated,  and  if  operative  interference  is  indicated  the  proper 
type  of  operation  is  more  easily  chosen.  If  the  disease  is  allowed  to  progress 
without  appropriate  treatment,  the  disease  makes  its  way  to  the  surface, 
peri-articular  abscesses  develop,  the  skin  becomes  involved,  and  the  sur- 
roundings of  the  joint  are  riddled  with  sinuses. 

Diagnosis 

The  actual  diagnosis  is  made  by  attention  to  the  characteristic  grouping 
of  symptoms  and  physical  signs.  Differential  diagnosis  necessitates  the 
exclusion  of — 

(1)  Specific  Metaphysitis. — The  metaphysis  of  the  humerus  is  often 
affected  with  this  disease.  It  is  distinguished  from  tuberculous  disease  by 
the  fact  that  it  is  usually  multiple,  and  that  there  are  other  unmistakable 
evidences  of  specific  disease. 

(2)  Post-traumatic  Stiffness. — Injuries  to  the  elbow-joint  are  often 
bandaged  into  a  position  of  full  flexion  and  kept  so  for  some  weeks  ;  there 
necessarily  results  for  some  time  a  considerable  degree  of  stiffness,  and  a 
mistake  may  be  made  in  ascribing  the  limitation  of  movement  to  tuberculous 
disease. 

Prognosis 

If  the  case  is  treated  at  an  early  stage  the  prognosis  is  good,  and  a  joint 
with  a  fair  degree  of  movement  may  be  assured.  Should  ankylosis  occur  with 
the  arm  in  a  suitable  position,  there  is  wonderfully  little  inconvenience. 
If  operative  treatment  has  become  necessary  and  excision  is  done,  there  is 
a  possibility  of  the  joint  becoming  flail.  The  prognosis  as  regards  life  has 
none  of  the  gravity  which  one  associates  with  disease  of  the  shoulder-joint. 

Treatment 

Conservative. — Fixation  Treatment. — Here,  as  elsewhere,  the  con- 
servative treatment  consists  in  placing  the  joint  at  rest  in  such  a  position 
that  should  ankylosis  occur  the  patient  will  suffer  the  least  possible  incon- 
venience. The  ideal  position  is  one  of  flexion  to  a  little  less  than  a  right 
angle  with  the  forearm  midway  between  pronation  and  supination. 

The  Halter  Sling} — The  arm  is  bent  to  the  jJroper  degree  of  flexion. 
It  is  kept  in  this  position  by  a  broad  bandage,  which  is  sufficiently  long  to 
pass  round  the  wrist  once  or  twice  and  thence  round  the  neck.  The  knots 
at  the  wrist  and  neck  are  sealed  to  ensure  that  the  bandage  is  not  disturbed. 
No  other  means  of  fixation  is  necessary.     It  adds  to  the  comfort  of  the 

1  Jones  and  Ridlon,  Contribution  to  Orthopcedic  Surgery,  p.  241. 


IT, ATI-;   L.— Advanced  Tubehculous  Ijiskask  ok  the  Kuuuw-Joint. 
Tlie  luticul.ir  siirfacu  of  tlie  uliia  is  prueticnlly  destroyed. 


TUBERCULOUS  DISEASE  OF  ELBOW-JOINT 


315 


patient  to  have  that  portion  of  the  bandage  which  passes  round  the  back 

of  the  neck  threaded  upon  a  piece  of  rubber  tubing ;  the  bandage  is  attached 

below  to  a  leather  wristlet.      The   arm   is 

carried  next  to  the  body  with  all  the  garments 

above  it.    In  the  event  of  its  being  impossible 

to  bend  the  arm  to  the  proper  degree  of 

flexion,  a  modification  of  the  halter  is  used. 

If  the  wrist  cannot  be  brought  to  the  neck, 

the  neck  is  brought  to  the  hand,  and  in  this 

position  the  halter  is  adjusted.     Very  soon 

the  discomfort  of  the  position  induces  the 

patient  to  bend   the   elbow  sufficiently   to 

permit    of    straightening    the    head.      The 

manoeuvre  is  repeated  until  the  proper  degree 

of  flexion  is  obtained. 

Plaster  of  Paris. — This  is  sometimes  used 
as  a  splint.  It  secures  excellent  fixation,  but 
discomfort  is  often  complained  of.  If  it  is 
impossible  to  flex  the  arm  sufficiently  at  the 
first  application,  the  plaster  should  be  applied 
in  two  portions,  one  to  the  upper  arm  and 
one  to  the  forearm.  Opposite  the  elbow  a 
space  of  nearly  3  inches  is  left.  The  space 
is  bridged  in  front  by  a  strip  of  aluminium    Fig.  154.-The  halter  sling  for  use  in 

,         .  ,         ,  If,  •  •         tuberculous  disease  of  the  elbow-joiut. 

1   inch  wide,  the  ends  of  the  strip  are  in- 
corporated in  the  plaster  above  and  below.      From  time  to  time  the  joint 
is  bent  until  the  proper  degree  of  flexion   is  reached.      There  are  other 
varieties  of  splints  which  may  be  used,  such  as  poro-plaster,  celluloid,  and 
aluminium. 

Afier-lrealment. — The  fixation  splint  should  be  kept  in  position  until 
such  a  time  as  the  disease  is  thoroughly  and  entirely  cured,  necessitating 
a  period  of  not  less  than  eighteen  months.  At  the  end  of  that  time,  if  anky- 
losis has  occurred,  it  is  not  advisable  to  take  steps  to  procure  some  movement 
in  the  joint.  If  the  cessation  of  active  treatment  lias  left  a  joint  with  a 
certain  degree  of  movement,  the  patient  is  allowed  gradually  to  use  the 
joint,  at  first  slight  and  sinijjk'  active  movements,  and  then  more  thorough 
movements  entailing  some  degree  of  weight-lifting. 

Additional  Means  of  Conservative  Treatment. — The  elbow  is  well  suited 
for  treatment  by  Bier's  congestion  bandage.  The  application  is  made  at 
the  middle  of  the  upper  arm.  Tlie  details  of  the  treatment  have  been  already 
discussed.  Medicated  injections  into  the  joint  are  recommended.  The 
most  suitable  ])oint  for  injection  is  immediately  above  the  head  of  the  radius, 
the  forearm  being  held  midway  between  pronation  and  supination,  and  the 
elbow  flexed  to  a  right  angle. 

Operative  Treatment.— foci.sw«  of  the  Elbow-joint.— Indications.  - 
The  conditions  wliicli  call  for  operation  are  similar  to  tliose  described  under 


316  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

the  headings  of  other  situations.  Briefly  they  are  the  presence  of  a  bone 
focus,  especially  one  which  is  tending  to  extend  along  the  centre  of  the  shaft 
of  the  humerus  ;  the  progression  of  the  disease  in  spite  of  conservative  treat- 
ment ;  the  development  of  peri-articular  abscesses  ;  and  the  presence  of 
sinuses  leading  into  the  joint. 

The  Ojjeration. — There  are  two  methods  of  excision  which  are  in  common 
use — excision  by  Langenbeck's  posterior  vertical  median  incision,  and  ex- 
cision by  the  lateral  J -shaped  incision  of  Kocher. 

Posterior  Excision. — The  operator  standing  on  the  affected  side,  the  arm 
is  held  across  the  table  in  a  position  of  partial  flexion  by  an  assistant.  An 
incision  is  made  in  the  middle  line  behind  from  2  inches  above  to  2  inches 
below  the  joint.  It  penetrates  to  the  bone  throughout,  it  passes  through 
the  triceps  on  to  the  posterior  surface  of  the  humerus,  it  opens  the  posterior 
part  of  the  joint,  and  it  exposes  the  olecranon  and  the  subcutaneous  surface 
of  the  ulna.  With  the  knife  and  periosteal  elevator  the  periosteum,  the 
triceps,  and  the  anconeus  are  separated  off  the  inner  and  the  outer  sides  of 
the  olecranon.  The  separation  is  carried  up  the  inner  part  of  the  lower  end 
of  the  humerus,  and  pronators  and  flexors  are  separated,  with  the  internal 
lateral  ligament  and  the  periosteum,  from  the  antero-lateral  aspect  of  the 
condyle  ;  the  lower  end  of  the  origin  of  the  triceps  is  separated  from,  the 
posterior  surface  of  the  humerus.  In  this  stage  of  the  dissection  there  is  a 
risk  of  injuring  the  ulnar  nerve,  as  it  lies  in  the  groove  between  the  olecranon 
and  the  internal  condyle.  It  is  preserved  by  raising  it  and  retracting  it 
inwards  with  the  rest  of  the  soft  structures. 

The  outer  half  of  the  elbow- joint  is  cleared,  the  anconeus  and  the  triceps 
have  already  been  separated  from  the  outer  side  of  the  olecranon.  The 
ligaments  covering  the  posterior  part  of  the  head  of  the  radius  are  exposed 
with  the  articular  ligament  and  the  supinator  brevis  at  successive  levels. 
A  small  part  of  the  supinator  brevis  should  be  separated  subperiosteally 
from  the  neck  of  the  radius  and  retracted  outwards.  The  outer  part  of  the 
humerus  is  cleared  from  the  attachment  of  the  anconeus,  and  the  origins  of 
the  extensors  and  the  external  lateral  ligament  are  divided.  There  is  thus 
effected  a  complete  decortication  of  the  posterior  and  lateral  surfaces  of  the 
bones  forming  the  elbow.  The  elbow  is  now  flexed,  and  the  posterior  liga- 
ment having  been  divided,  the  interior  of  the  joint  is  exposed.  By  flexing 
the  joint  acutely  the  lower  end  of  the  humerus  is  projected  from  the  wound 
and  the  soft  parts  (anterior  ligament  and  brachialis  anticus)  are  separated 
sufiiciently  from  its  anterior  surface.  If  no  disease  is  apparent  in  the 
humerus,  the  bone  is  divided  on  a  level  with  the  upper  part  of  the  epicondyles. 
If  a  focus  is  present  the  division  should  be  made  above  the  disease,  and  in 
the  event  of  this  being  impossible  the  focus  should  be  exposed  by  the  division 
and  thoroughly  curetted  out  from  the  cut  surface. 

Attention  is  directed  to  the  radius  and  ulna,  the  orbicular  ligament  is 
retained  if  possible,  but  the  neck  of  the  radius  divided  well  below  the  head. 
The  attachments  of  the  anterior  ligament  and  the  brachiahs  anticus  to  the 
coronoid  process  of  the  ulna  are  separated  subperiosteally,  and  the  articular 


TUBERCULOUS  DISEASE  OF  ELBOW-JOINT 


317 


surface  of  the  ulna  removed  to  expose  a  concave  svirface.  The  division 
of  all  the  bones  is  preferably  made  with  a  narrow  ribbon  butcher's  saw,  and  the 
section  is  carried  from  before  backwards  to  avoid  possible  injury  to  the 
vessels. 

After  removal  of  the  articular  surfaces  all  diseased  synovial  membrane 
is  systematically  cleared.  Attention  is  paid  to  the  posterior  ligament  and 
the  pouch  beneath  the  triceps,  to  the  surface  of  the  orbicular  ligament  and  the 
recessus  sacciformis,  and  finally  to  the  anterior  ligament  with  its  membrane. 
Iodoform  and  bismuth  paste  is  well  rubbed  into  the  interior  of  the  joint. 
The  soft  parts  are  restored  as  far  as  possible  into  their  proper  position.  The 
muscles  detached  from  the  lateral  aspects  of  the  humerus  are  sutured  back 
with  the  periosteum  if  possible.  The  split  edges  of  the  triceps  are  brought 
together,  and  the  separated  attachments  of  the  triceps  and  anconeus  are 
brought  over  the  remains  of  the  olecranon.  The  supinator  brevis  is  sutured 
either  behind  the  neck  or  over  the  cut  surface  of  the  radius.  In  the  absence 
of  mixed  infection  drainage  is  unnecessary. 

Kocher's  Excision. — Kocher  claims  as  an  advantage  for  his  operation 
that  the  joint  is  thoroughly  exposed  with  a  minimum  of  interference  to  the 
nerve  supply  of  the  muscles.  Only  the  special  points  of 
the  operation  will  be  dealt  with.  Beginning  at  a  point  2 
inches  above  the  joint,  the  incision  is  carried  dowai  along 
the  back  of  the  external  supra-condyloid  ridge  over  the 
radio-humeral  joint  and  the  head  of  the  radius,  and  along 
the  outer  margin  of  the  anconeus  between  that  muscle  and 
the  extensor  carpi  ulnaris  to  the  ridge  of  the  ulna  2  inches 
below  the  tip  of  the  olecranon.  At  the  upper  end  of  the 
incision  the  outer  edge  of  the  humerus  is  exposed  by 
separating  the  supinator  longus  and  the  extensor  carpi 
radialis  longior  in  front  from  the  triceps  behind.  Below 
the  level  of  the  joint  the  ulna  is  exposed  by  separating 
between  the  e.xtensor  carpi  ulnaris  and  the  anconeus.  A 
flap  is  then  turned  inwards,  consisting  of  the  triceps,  a 
scale  of  cartilage  from  the  olecranon  carrving  the  insertion  „  ,,  ,.  ,  , 
of  the  triceps,  and  the  anconeus.  Ihe  ulnar  nerve  is  incision  for  ex- 
separated  inwards  with  the  flap,  the  nerve  supply  to  the  iis'onoftheelbow- 
anconeus  entering  the  deep  surface  of  the  muscle  is  pre- 
served. With  the  exposure  of  the  posterior  surface  of  the  joint  the  steps 
of  the  operation  are  similar  to  those  already  described. 

When  the  diseased  tissues  have  been  removed  the  soft  parts  are  restored 
to  position.  The  posterior  detached  flap  is  brought  back  and  sutured  to  tiie 
external  intermuscular  septum  and  the  muscles  arising  from  it  (supinator 
longus  and  the  extensor  va.T\n  radialis  longior)  above  the  outer  edge  of  the 
triceps  tendon.  Below,  the  outer  margin  of  tlie  anconeus  is  united  to  tiie 
common  origin  of  the  extensors  and  to  the  inner  surface  of  the  extensor 
carpi  ulnaris. 

After-lrealmenl.     When   the  dressing   is  applied  tlie   ami   is   fastened 


318  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

to  the  side  of  the  chest  in  a  position  of  extension  and  moderate  supination. 
The  arm  is  kept  in  this  position  until  the  wound  is  firmly  healed,  a  period 
usually  of  two  or  three  weeks.  At  the  end  of  that  time  and  for  the  next 
two  weeks  the  arm  is  kept  fully  flexed  and  fully  extended  for  alternate 
periods  of  twenty-four  hours.  In  obtaining  the  first  flexion  it  will  probably 
be  necessary  to  administer  a  general  ana3sthetic.  Four  or  five  weeks  after 
the  operation  the  arm  is  carried  in  a  sling,  and  the  patient  allowed  to  bring 
it  into  gradual  use.  Massage  is  useful  in  reducing  the  post-operative  stiffness. 
Results  of  Excision  of  the  Elboiv-joint. — Mr.  Stiles  has  reported  the 
results  of  excision  in  54  instances.  Each  case  was  an  example  of  advanced 
disease,  which  had  failed  to  improve  under  proper  conservative  treatment. 
In  28  cases  there  was  abscess  formation,  and  10  cases  were  complicated  by 
sinuses.  Of  the  54  excisions,  34  were  traced  at  the  end  of  a  period  of  ten 
years  from  the  date  of  the  first  operation.  There  was  no  immediate  mortality 
from  the  operation,  but  6  cases  died  subsequently,  each  as  the  result  of 
general  tuberculosis.  In  8  instances  there  was  a  recurrence  of  the  disease, 
trivial  in  all  cases  save  one,  which  required  amputation.  Of  the  functional 
results  it  could  be  said  that  in  10  cases  the  ultimate  result  was  distinctly 
good.  In  6  instances  the  arm  was  ankylosed  in  a  position  which  permitted 
the  patient  to  carry  out  the  functions  of  the  part.  In  7  cases  the  joint  was 
somewhat  flail,  and  while  active  movements  were  satisfactorily  executed, 
the  power  of  weight-lifting  was  naturally  limited.  The  average  amount  of  ■ 
shortening  was  l-i  inches,  the  maxinmm  was  2|  inches,  and  the  minimum 


2  inch. 


BIBLIOGRAPHY 


Losses,  W.     "  Beitrage  zur  extrakapsularen   radikal  Resektion  der  tuberkulosen  Ellen- 

bogengelenke,"  Deutsche  Zdtschr.  f.  Chir.,  1905,  xcii.  120-155. 
Dawbakn,  R.  H.  M.     "  Excision  of  the  Elbow,"  Internal.  J.  Surg.,  New  York,  1908,  xxi. 

348. 
COTTAM,  C.    G.     "  The  Early  Restoration  of  Function  after  Excision  of  the  Tuberculous 

Elbow-joint,"  Am.  J.  Surg.,  New  York,  1908,  xxii.  108. 
ScHONiEDLER,  V.    "  Uber  EUenbogenresektion  mit  Erhaltung  der  Beweglichkeit,"  Berlin,  klin . 

Wochenschr.,  1908,  xlv.  1521. 
Habtwell,   J.   A.     "  Resection   of   Tuberculous   Elbow,"   Am.   Stirg.,   Philadelphia,    1908, 

xlviii.  454. 
Hancock,  I.  H.     "  Resection  of  the  Elbow-joint,"  Internat.  J.  Surg.,  New  York,  1909,  xxii. 

73. 
IsELiN,  H.     "  Gabelgelenk  am  Ellenbogen  nach  teilweiser  Resektion  in  Kindesalter,"  Deutsche 

Zeitschr.  fur  Chir.,  1909,  xcviii.  571. 
CUMSTON,  C.  G.     "  Resection  of  the  Elbow  in  Children,"  N.  York  M.J.,  1910,  xcii.  297-301. 
Remer,  H.     "  Uber  die  funktionellen  Resultate  der  Resektion  EUenbogengelenkes  rait  Inter- 
position ernes  Muskellappens  nach  Helferich,"  Deutsche  Zeitschr.  fur  Chir.,  Leipzig,  1910, 

civ.  209-240. 
Sever,  J.  W.     "  Tuberculosis  of  the  Elbow,"  Boston  31.  and  S.  Journal,  1910,  clxii.  666-669. 
Ross,  G.  C.     "  Tuberculous  Arthritis  of  the  Elbow,"  Tr.  Phila.  Acad.  Surg.,  Philadelphia, 

1912,  xiv.  91. 
Heckmann,  J.     ''  Tuberculosis  of  the  Elbow  treated  by  Bismuth  Paste  Injections,"  Post 

Graduate,  New  York,  1913,  xxviii.  252-254. 


TUBERCULOUS  DISEASE  OF  WRIST-JOINT  319 


TUBERCULOUS  DISEASE   OF  THE   WRIST-JOINT 

Etiology 

One's  experience  has  been  that  tuberculous  disease  of  the  wrist-joint  is 
distinctly  rare  in  children,  and  in  the  statistics  of  a  large  number  of  joints 
it  has  been  found  to  occur  in  a  proportion  of  2  per  cent.  The  right  wrist  is 
more  commonly  affected  than  the  left,  a  circumstance  which  is  explained 
by  the  greater  liability  to  injury  and  the  greater  degree  of  strain  borne  by 
that  side. 

Pathology 

Anatomy  of  the  Joint. — The  characteristics  of  the  joint  are  the  multi- 
plicity of  the  carpal  bones  and  the  corresponding  intricacy  of  the  synovial 
cavities.  Between  the  lower  articulation  of  radius  and  ulna  there  is  a  synovial 
cavity  to  which  the  term  recessus  sacciformis  inferior  has  been  applied. 
The  lower  end  of  the  radius  and  the  triangular  fibro-cartilage  at  the  lower 
end  of  the  ulna  articulate  with  the  scaphoid,  semi-lunar,  and  cuneiform  bones, 
and  at  the  articulation  there  is  an  extensive  synovial  space.  There  is  a 
small  synovial  sac  uniting  the  pisiform  bone  to  the  underlying  cuneiform. 
Between  the  rows  of  carpal  bones  there  is  the  elaborate  transverse  carpal 
joint,  which  sends  synovial  pouches  between  the  individual  bones.  Finally, 
there  are  two  carpo-metacarpal  joints,  a  single  one  between  the  trapezium 
and  the  first  metacarpal  bone,  and  a  complicated  one  between  the  trapezoid, 
OS  magnum,  and  unciform,  and  the  four  inner  metacarpals.  At  birth  the 
carpus  is  entirely  cartilaginous.  The  os  magnum  and  the  unciform  are  the 
first  bones  to  beconie  ossified. 

Pathological  Anatomy. — The  possible  origin  of  the  disease  in  the 
wrist-joint  may  be  synovial  or  osseous,  and  by  far  the  greater  proportion 
originate  in  a  bone  lesion.  The  common  situations  are  the  lower  end  of  the 
radius  and  certain  of  the  carpal  bones  ;  the  metacarpal  bases  are  rarely 
affected.  Of  the  individual  carpal  bones  the  os  magnum  is  the  most  frequently 
diseased,  probably  on  account  of  the  fact  that  it  is  the  first  to  become  ossified. 
The  disease  does  not  long  remain  localised  by  the  osseous  tissue,  it  soon 
bursts  its  way  through  the  thin  limiting  shell  and  infects  the  jouit  around. 
From  the  pressure  of  the  different  bones,  a  diseased  carpal  bone  soon 
gives  way,  and  as  it  does  so  there  is  a  dissemination  of  diseased  material 
into  the  joints  on  all  sides  of  it.  Therefore,  wrist  disease  originating  in  a 
carpal  bone  is  likely  to  be  more  extensive  than  an  infection  secondary  to 
a  focus  in  the  radius  or  metacarpal. 

There  is  nothing  peculiar  about  the  pathology  in  cither  bone  or  synovial 


320 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


membrane.  As  the  disease  extends,  it  soon  comes  into  contact  with  the 
synovial  membrane  of  the  tendon  sheaths,  usually  on  the  flexor  aspect. 
The  sheath  lining  undergoes  a  degeneration  exactly  similar  to  the  tuberculous 
change  which  occurs  in  syno\'ial  membrane.  The  tendon  itself  becomes 
infiltrated  and  destroyed,  and  the  sheath  is  distended  with  a  viscous  fluid 
containing  melon-seed  bodies  moulded  from  lymph  deposited  on  the  surface 
of  the  tendon.  In  neglected  cases  peri-articular  abscesses  and  sinuses 
develop. 


Fig.  156. 


-Tuberculous  disease  of  the  wrist-joint.     There  is  the 
characteristic  swelling  on  tile  dorsum. 


Clinical  Features 

Pain. — Pain  is  a  leading  feature.  At  first  it  is  localised  to  the  original 
site  of  the  disease,  it  then  becomes  more  general  and  gives  the  feeling  of  an 
increasing  tightness  around  the  wrist.     It  is  accentuated  by  pressure  and  by 

any  movement  of  which 
the  wrist-joint  is  capable. 
If  the  lower  end  of  the 
radius  is  diseased,  pain  is 
said  to  be  produced  by 
pressing  the  lower  ends  of 
radius  and  ulna  together. 
Swelling. — The  super- 
ficial position  of  the  joint 
renders  the  early  detec- 
tion of  a  swelling  probable.  Originally  it  appears  in  the  hollow  upon  each 
lateral  aspect  of  the  joint,  and  later  it  extends  in  a  bracelet-like  manner 
all  round  the  joint.  The  tendon  sheaths  are  displaced  and  rendered  more 
prominent,  and  if  they  become  invaded  by  the  disease  the  characteristic 
dumb-bell  shaped  swelling  of  the  compound  palmar  ganglion  is  produced. 
The  swelling  of  a  fully 
developed  case  of  wrist- 
joint  disease  is  character- 
istically fusiform  in  out- 
line. Entire  absence  of 
swelling,  other  symptoms 
being  present,  points  to 
a  purely  osseous  lesion. 

Deformity.  —  The 
hand  is  sometimes  held 
straight  in  the  axis  of  the  forearm,  more  commonly  it  is  held  flexed  to  an 
angle  of  about  120  degrees. 

Limitation  of  Movement. — All  the  movements  of  the  joint  become 
limited,  and  if  the  condition  is  left  untreated,  movement  is  entirely  lost  and 
the  hand  is  held  in  the  flexed  position.  Accompanying  the  limited  power 
of  movement  there  is  a  characteristic  spasm  of  the  long  muscles  passing  over 
the  wrist-joint. 


Fig.  157. — Tuberculous  disease  of  the  wrist-joint. 


TUBERCULOUS  DISEASE  OF  WRIST-JOINT  321 

Muscular  Atrophy. — The  wasting  is  most  marked  in  the  forearm ;  the 
short  muscles  of  the  hand  long  remain  well  nourished. 

Abscesses. — If  abscesses  develop  they  usually  appear  on  the  dorsum  of 
the  wrist  and  hand. 

Diagnosis 

There  is  nothing  to  be  said  in  diagnosis  apart  from  the  points  which 
have  been  discussed  in  other  situations. 

Prognosis 

The  prognosis  as  regards  function  in  cases  treated  early  should  be  good. 
In  a  certain  proportion  the  disease  is  complicated  by  pulmonary  tubercle, 
and  in  these  the  prognosis  is  bad. 

Treatment 

Conservative. — Complete  fixation  is  the  main  principle  in  the  con- 
servative treatment  of  the  disease.  To  this  essential,  auxiliary  methods 
may  be  added  in  the  shape  of  Bier's  congestion  and  injection. 

Fixation  Treatment. — The  wrist  is  an  easy  joint  to  control.  It  must 
be  fixed  in  a  position  of  moderate  dorsi-flexion,  as  this  attitude  permits  the 
flexor  muscles  to  close  the  fingers  easily  if  the  joint  becomes  fixed  by  disease. 
Aluminium  makes  an  excellent  splint ;  it  is  padded  with  boracic  liut ;  it 
extends  from  beyond  the  fingers  to  the  upper  part  of  the  forearm, and  opposite 
the  wrist  it  is  moulded  to  fit  the  position  of  dorsi-flexion.  Between  the  digits 
pieces  of  powdered  cotton- wool  are  laid,  and  the  splint  is  fastened  to  the 
arm  and  hand  with  strips  of  adhesive  plaster  ;  the  fingers  are  kept  bent. 
It  is  important  to  ensure  that  the  thumb  is  included.  A  covering  bandage 
is  applied  to  keep  the  part  clean.  A  light  plaster  bandage  may  be  used. 
The  forearm  and  fingers  are  covered  with  boracic  lint,  and  a  plaster  bandage 
is  applied  from  the  finger-tips  to  the  elbow,  the  hand  being  kept  in  the  proper 
position  of  slight  dorsi-flexion.  Silicate  of  potassium  or  celluloid  splints 
may  be  used  in  preference  to  plaster  of  Paris. 

Jones  Splint. — Robert  Jones  has  employed  a  simple  form  of  adjustable 
splint,  which  will  be  understood  by  reference  to  Fig.  158. 


Fig.  168. — Jones's  splint  for  the  treatnitnt  of  tulierculous  wrist  Uiseivse. 
Xote  tlie  ilorsitlcxeil  position  of  the  Imnil. 

Afler-treattnenl. — Complete  fixation  is  continued  until  there  is  aatis- 

21 


322  TUBERCULOSIS  OF  THE  BONES  AKD  JOINTS 

factory  evidence  of  the  disease  being  thoroughly  healed  ;  a  period  of  at  least 
eighteen  months  is  necessary.  The  splint  must  be  removed  gradually ; 
at  first  it  is  so  far  shortened  that  movements  of  the  phalanges  and  then  of 
the  metacarpo-phalangeal  joints  are  permitted,  complete  movement  of 
the  thumb  is  allowed,  and  finally  the  splint  is  removed.  Comfort  is  derived 
by  using  a  stiff  leather  wristlet  for  some  time  after  the  fixation  splint  has  been 
given  up. 

Operative  Treatment. — Excision.  Oilier  s  Operation. — The  author 
recommends  Ollier's  operation  because  it  is  accompanied  by  a  minimum 
of  disturbance  of  the  overlying  tendons  and  soft  parts.  Upon  the  back  of 
the  hand  two  landmarks  are  delimited,  namely,  the  inter-styloid  line  and 
the  base  of  the  second  metacarpal  bone.  Beginning  at  the  middle  of  the 
dorsal  aspect  of  the  second  metacarpal  bone,  an  incision  is  made  along  the 
radial  side  of  the  extensor  indicis  upwards  and  inwards.  When  the  incision 
reaches  the  level  of  the  inter-styloid  line  it  changes  its  direction  and  rims 
parallel  to  the  axis  of  the  forearm  for  about  IJ  inches.  On  the  ulnar  side 
of  the  wrist  a  second  straight  incision  is  made  from  a  point  1 J  inches  above 
the  tip  of  the  styloid  process  to  a  point  f  of  an  inch  below  the  base  of  the 
fifth  metacarpal  bone.  This  incision  lies  to  the  inner  side  of  the  extensor 
carpi-ulnaris,  and  it  penetrates  directly  to  the  bone.  By  the  outer  incision 
the  tendon  of  the  extensor  indicis  is  exposed  lying  in  its  sheath.  Without 
opening  the  sheath  both  are  retracted  inwards.  The  insertion  of  the  ex- 
tensor carpi-radialis  brevior  is  exposed,  and  the  periosteum  to  its  inner  side 
having  been  incised,  the  periosteum  with  the  insertion  of  the  muscle  is 
separated  outwards.  The  periosteal  incision  is  carried  upwards,  dividing 
the  capsule  of  the  joint  and  the  posterior  annular  ligament  between  the 
extensor  indicis  and  the  extensor  pollicis  longus.  The  posterior  surface 
of  the  carpus  is  now  exposed  through  two  incisions,  and  through  either  of 
them  the  ligamentous  structures  are  separated  from  the  bones.  If  the 
separation  is  properly  carried  out  the  various  tendinous  insertions  are 
preserved.  The  semi-lunar  bone  should  first  be  removed,  as  it  lies  exposed 
by  the  outer  incision.  The  cuneiform  is  then  dissected  out,  and  room 
obtained  to  deal  with  the  unciform,  the  hook  of  which  is  chipped  off  with 
bone  forceps,  while  the  body  of  the  bone  is  removed.  The  pisiform  bone  is 
left  in  situ  and  so  is  the  trapezium,  unless,  of  course,  it  happens  to  be  diseased. 
After  removal  of  the  carpal  bones  the  lower  ends  of  the  radius  and  ulna  with 
the  triangular  cartilage,  if  diseased,  are  removed.  If  possible,  the  carpal 
ends  of  the  metacarpal  bones  are  not  interfered  with.  Before  closing  the 
wound  sublimated  iodoform  bismuth  jiaste  is  rubbed  into  the  raw  surfaces. 
If  drainage  is  necessary  it  is  secured  by  pulling  a  rubber  drain  through  from 
one  incision  to  another. 

After-treatment. — It  is  important  in  the  after-treatment  to  ensure  that 
the  hand  is  maintained  in  the  dorsi-flexed  position  with  the  thumb  and 
fingers  free.  For  this  purpose  a  bent  aluminium  anterior  splint  is  used  ;  or 
a  Lister's  splint,  which  is  an  anterior  wooden  splint  thickened  opposite 
the  metacarpals  by  means  of  a  cork  pad,  is  employed.     The  splint  is  kept 


TUBERCULOUS  DISEASE  OF  WRIST-JOINT  323 

in  position  until  the  parts  are  thoroughly  consolidated.     After  the  wound  is 
healed  the  fingers  are  carefully  massaged. 

BIBLIOGRAPHY 

KuNNEE.     "  La  Tumeur  blanche  du  poignet,"  Rev.  med.  de  la  Suisse  Eotn.,  Geneve,  1908, 

xxviii.  153. 
VlLLAKD.     "  Resection  du  poignet  et  plombage,"  Lyon  chirtirg.,  1908-9,  i.  306. 
Reverden,  J.  L.     "  L'Arthrite  tuberculeuse    du  poignet  droit,"  Eei:   med.  de    la  Suisse 

Rom.,  Geneve.  1908,  xxviii.  248. 
Gerard,  L.  M.     "  La  Tuberculose  du  poignet  chez  I'enfant,"  Rev.  internat.  de  la  tuberc, 

Paris,  1909,  .xvi.  21-38. 
BoSQHETTE.     "  Tumeur  blanche  du  poignet,"  Dauphine  med.,  Grenoble,  1909,  xxxiii.  128-130. 


324  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


SACRO-ILIAC  DISEASE 
Etiology 

Sacro-iliac  disease  is  uncommon  at  all  periods  of  life,  and  during  child- 
hood its  occurrence  is  distinctly  rare.  Van  Hook,i  out  of  a  total  of  72  cases 
of  sacro-iliac  disease,  found  it  occurring  in  children  in  only  6  instances.  The 
explanation  of  this  age  incidence,  so  different  from  tuberculous  disease 
elsewhere,  is  said  to  be  as  follow-s  :  the  disease  appears  to  be  predisposed 
to  by  a  series  of  multiple  traumatisms,  and  in  children  it  is  unlikely  that 
these  are  sustained.  It  is  often  noticed  that  the  young  patients  who  do 
fall  victims  to  the  disease  are  children  who  are  addicted  to  violent  forms 
of  sport  and  exercise. 

Pathology 

Anatomy  of  the  Joint. — The  joint  is  formed  by  the  contiguous 
auricular  surfaces  of  the  sacrum  and  the  ilium,  and  it  constitutes  a  diar- 
throdial  joint.  The  joint  cavity  is  surrounded  by  strong  ligaments  which 
constitute  the  joint  capsule.  The  anterior  ligament  is  thin,  while  the 
posterior  ligaments,  two  in  number,  are  strong.  The  latter  are  largely 
responsible  for  suspending  the  sacrum  and  the  weight  of  the  superimposed 
trunk  from  the  innominate  bones.  The  joint  is  lined  by  a  rudimentary  and 
imperfect  synovial  membrane. 

Patholog'y. — The  disease  may  occm-  on  either  side  of  the  body ;  it  is 
exceedingly  rare  for  it  to  appear  upon  both  sides  simultaneously.  It  has 
been  described  as  originally  occurring  in  the  bone  and  in  the  synovial  mem- 
brane ;  owing  to  the  very  imperfect  development  of  the  synovial  membrane 
the  second  possibility  is  unlikely.  The  osseous  disease  may  appear  in  the 
articular  surface  of  the  ilium  or  in  the  lateral  mass  of  the  sacrum.  The 
sacrum  is  the  more  common  position,  and  the  disease  often  extends 
into  this  situation  from  the  lower  lumbar  vertebrae.  From  the  osseous 
disease  the  synovial  membrane  becomes  infected,  and  the  disease  may  extend 
across  the  joint  to  attach  the  articulating  surface  of  the  iliac  bone.  There 
is  nothing  characteristic  in  the  detailed  pathology  of  the  disease,  either  in 
bone  or  joint,  beyond  the  fact  that  the  tendency  to  cold  abscess  formation 
is  more  prominent  than  is  usually  the  case.  The  pus  may  make  its  way  in 
various  directions.  It  may  pass  backwards  and  become  superficial,  but 
owing  to  the  strength  and  arrangement  of  the  posterior  ligaments  this  route 
is  not  commonly  chosen.  More  frequently  it  forces  its  way  through  the  thin 
anterior  ligament,  and  becomes  intrapelvic.  The  intrapelvic  abscess  may 
extend  outwards  into  or  behind  the  sheath  of  the  psoas  appearing  with  the 

'  Ann.  of  Surgery,  vol.  viii.  p.  40]. 


SACRO-ILIAC  DISEASE  325 

muscle  in  the  groin,  it  may  extend  still  further  out  beneath  the  iliacus  and 
become  superficial  internal  to  the  anterior  superior  iliac  spine,  or  it  may  pass 
directly  downwards  and  appear  on  the  buttock  through  the  sacro-sciatic 
notch  and  in  the  ischio-rectal  fossa. 

Clinical  Features 

Pain. — Pain  is  usually  the  first  symptom  to  appear.  It  is  situated  over 
the  affected  joint,  and  it  radiates  down  the  back  of  the  thigh  and  upwards 
towards  the  lumbar  region.  The  actual  symptom  of  pain  is  often  ushered 
in  by  indefinite  complaints  of  weakness  and  discomfort  in  the  lower  part 
of  the  back  and  sacrum,  and  a  sensation  as  though  the  body  was  giving  way. 
Pain  is  increased  by  standing,  stooping,  and  walking,  by  defaecation,  and  by 
pressing  the  iliac  bones  together.  It  is  considerably  relieved  when  the 
patient  lies  down.  As  the  disease  progresses  the  pain  becomes  more  constant 
and  severe. 

Limp,  Attitude,  mid  Gait. — The  lameness  is  probably  first  noticed  at 
the  close  of  a  heavy  day's  work.  The  gait  is  characteristic,  the  patient 
takes  short  hesitating  steps,  and  he  may  drag  the  afiected  leg.  The  attitude 
is  distinctive.  The  pelvis  is  tilted  upwards  upon  the  diseased  side,  and  the 
great  burden  of  support  is  accordingly  thrown  on  the  sound  side.  There  is 
a  compensating  scoliosis  in  the  dorso-lumbar  spine  with  the  convexity 
towards  the  sound  side. 

Changes  in  the  Limbs. — The  gluteal  muscles  on  the  affected  side  become 
considerably  atrophied.  Apparent  shortening  of  the  affected  limb  is  noted 
on  account  of  the  tilting  upwards  of  the  pelvis. 

Sivelling. — Swelling  may  be  apparent  over  the  joint  behind.  Very 
frequently  rectal  examination  will  demonstrate  a  swelling  on  the  anterior 
aspect  of  the  joint. 

Abscess  Formation. — Fluctuation  may  be  detected  posteriorly  over  the 
sacro-iliac  joint ;  it  may  be  detected  by  rectal  examination  while  intrapelvic, 
or  the  intrapelvic  abscess  may  be  recognised  in  its  various  superficial  situa- 
tions, psoas,  iliac,  or  sciatic.  Palpation  shows  that  the  local  temperature  over 
the  joint  is  raised. 

Diagnosis 

The  actual  diagnosis  is  made  by  the  position  of  the  pain  and  of  the 
early  swelling,  by  the  radiation  of  the  pain,  and  by  the  elicitation  of  the  pain 
on  bilateral  pressure.  In  differential  diagnosis  there  are  four  conditions 
liable  to  be  mistaken  for  sacro-iliac  disease — these  are  lumbago,  sciatica, 
hip  disease,  and  Pott's  disease. 

Lumbago  is  recognised  by  the  bilateral  ciiaiactcr  ul  the  pain  and  the 
situation  of  tlie  occurrence. 

Sciatica  is  confined  in  its  distribution  to  the  sciatic  nerve.  Sacro-ilinc 
disease  radiates  upwards  as  well  as  downwards  ;  n^.oreover,  sciatica  is  exceed- 
ingly uncommon  in  children. 


326  TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 

Hip  disease  can  be  excluded  by  careful  examination,  and  the  demonstra- 
tion of  muscular  rigidity  in  the  hip-joint. 

Lumbar  Pott's  disease  may  be  exceedingly  difficult  to  exclude.  An 
X-ray  will  help,  and  also  the  fact  that  lateral  pressure  on  the  iliac  spines 
elicits  local  pain  in  sacro-iliac  disease. 

Prognosis 

The  prognosis  in  children  is  said  to  be  more  favourable  than  in  adults. 
The  gravity  of  the  prognosis  is  increased  by  abscess  formation,  especially  if 
in  treatment  a  mixed  infection  is  set  up.  The  affection  is  extremely  chronic, 
and  the  necessary  treatment  is  prolonged. 

Treatment 

General. — The  patient  should  be  put  under  such  conditions  that  he 
gets  the  greatest  possible  benefit  from  improved  general  treatment. 

Conservative.  —  Recumbent  Treatment. — During  the  acute  and  the 
progressive  stages  of  the  disease,  complete  rest  in  bed  is  essential.  The 
patient  is  fixed  in  a  double  Hamilton  or  Bryant  splint,  or  in  a  bed  frame. 
Comfort  is  derived  by  affording  the  patient  the  benefit  of  weight  extension. 
Jones  and  Eidlon  ^  recommend  a  modified  double  Thomas  splint ;  the  vertical 
stems  of  the  splint  pass  to  the  outer  side  of  the  posterior  superior  iliac  spines; 
and  about  the  middle  they  are  connected  by  a  broad  leather  sling  which 
extends  from  the  coccyx  to  the  mid-lumbar  region.  Recumbent  treatment 
is  continued  until  all  acute  symptoms  have  disappeared,  and  as  long  as  there 
is  any  risk  of  abscess  formation  occurring. 

Ambulatory  Treatment. — In  going  about,  the  patient  wears  a  patten 
upon  the  sole  of  the  boot  of  the  healthy  side.  It  is  advisable  that  the  boot 
sole  on  the  diseased  side  be  weighted  with  lead,  as  in  this  way  a  moderate 
and  continuous  extension  is  secured.  It  is  necessary  to  afEord  some  support 
to  the  diseased  region  and  to  the  spine.  A  simple  broad  lacing  band  of  leather 
or  jean  may  be  sufficient ;  it  extends  from  2  inches  below  the  tip  of  the  great 
trochanter  to  an  inch  or  more  above  the  crest  of  the  ilium.  The  continuous 
pressure  of  the  band  does  not  induce  pain  as  does  intermittent  pressure  with 
the  hands.  Plaster  of  Paris  has  been  used  with  benefit.  It  passes  as  a 
broad  band  round  the  pelvis,  and  takes  a  fixed  point  by  passing  round  the 
upper  end  of  one  or  both  thighs.  A  double  Thomas  hip  splint,  altered  as 
already  described,  is  recommended,  crutches  and  a  high  boot  being  used. 
Its  use  is  probably  imnecessary  in  the  ambulatory  stage. 

Operative  Treatment. — Indications. — Operation  is  recommended  in 
early  cases  showing  by  X-ray  the  presence  of  a  local  osseous  focus,  also  in 
cases  which  are  passing  on  to  abscess  formation. 

Operation. — The  patient  is  placed  prone,  the  pelvis  being  raised  by  an 
anterior  pad.     A  vertical  semi-lunar  incision  is  made,  convex  inwards  and 

'  Jones  and  Ridlon,  Amials  of  Surgery,  vol.  xvii.  p.  291. 


SACRO-ILIAC  DISEASE  327 

internal  to  the  afltected  joint.  The  flap  is  separated  outwards.  The  fibres  of 
the  gluteus  maximus  and  gluteus  medius  with  the  great  sacro-sciatic  ligament 
and  periosteum  are  separated  from  the  posterior  surface  of  the  sacrum 
and  the  surface  of  the  ilium  and  retracted  outwards.  The  lower  part  of  the 
erector  spinse  is  separated  and  pulled  inwards.  The  posterior  surface  of 
the  joint  is  exposed,  covered  by  strong  posterior  ligaments.  Better  access 
is  got  by  removing  the  posterior  superior  and  inferior  spines  of  the  ilium. 
Disease  in  the  ilium  or  sacrum  is  removed  with  gouge  and  sharp  spoon ;  it 
may  be  necessary  to  remove  the  whole  articular  surface.  If  an  intrapehac 
abscess  is  present  it  is  emptied  and  any  diverticula  which  may  exist  are 
drained  with  counter  openings. 

After-treatment. — The  patient  is  of  coiirse  kept  at  rest.  Until  the 
wound  is  healed  the  child  is  kept  lying  upon  the  side  supported  with  sand 
pillows  ;  when  the  wound  is  healed  the  supine  position  is  maintained. 

BIBLIOGRAPHY 

Andrews,  C.  R.     "  Sacro-iliac  Disease,"  Charlotte  {N.C.)  M.J.,  1908,  Iviii.  309-313. 
Andkews,  C.  R.,  and  Hoke,  M.     "  Sacro-iliac  Disease,"  Atlantu  Journ.  Eec.  iled.,  1908-9, 

X.  241-250. 
Streda,  a.     "  Zur  Syraptomatologie  der  Tuberkulose  des  Iliosaeralgelenks,"  Berlin,  klin. 

Wochenschr.,  1909,  xlvi.  242-2-44. 
Genne.     "  Abces  froid  dii  a  un  sacro-coxalgie  et  traits  par  la  methode  Calot,"  Bull,  et  mem. 

Soc.  de  Med.  de  Vaiicluse,  Avignon,  1909,  v.  173-175. 
PiCQUE,  R.     "  Sacro-coxalgie  guerie  par    la  resection   sacro-iliaque,"  Bull,  et  mem.  Soc.  de 

Chir.  de  Par..  1909,  N.S.  xxxv.  915. 
Aller,  F.  H.     "  A  Study  of  the  Anatomy,  the  Clinical  Importance  of  the  Sacro-iliac  Joint," 

J.  Am.  M.  Ass.,  Chicago,  1909,  liii.  1273-1276. 
Dblbet.     "  Sacro-coxalgie,"   Med.  mod.,  Paris,   1910,  xxi.  250. 
BoGARDUs,  F.  B.     "  Tuberculosis  of  Os  Sacrum  treated  by  Bismuth  Paste,"  J.  Am.  M.  Ass., 

Chicago,  1910.  liv.  701. 
PiCQiE,  R.     "  Lc  Traitement  de  la  sacro-coxalgie  par  la  rdsection  sacro-iliaque,"  J.  de  chir., 

Paris,  1910,  v.  237-252. 
GoLDscinviND,  F.     "  Ein  Beitrag  an  der  Unfallpraxis  (Tuberkulo.se  der  Iliosakralgelenkes)," 

Munatsschr.  f.   Unjallkrankh.,  Leipzig,  1911,  xviii.  15-20. 
Parec'HET,  v.     "  Sacro-coxalgio,  son  traitement,"  Clinique,  Paris,  1911,  vi.  39. 
Wheeler,  W.   I.   do  C.     "  The  Early  Diagnosis  and  Treatment  of  Sacroiliac  Disease," 

Med.  Press  and  Circ,  London,  1911,  N.S.  xci.  673-077. 
Haar,  K.     Beitraij  zur  chiruryischen  Bekandlung  der  sacro-iliocacalen  Tuberkulose,  Heidelberg, 

1912,  J.  Horning. 


328 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


TUBERCULOUS  DISEASE  OF  THE  SKULL  BONES 


Etiology 

Children  are  liable  to  suffer  from  tuberculous  disease  of  the  skull  bones. 
Its  development  is  usually  secondar)'  to  tuberculous  disease  in  other  parts 
of  the  body.  As  in  other  situations,  injury  would  appear  to  play  its  part  in 
the  original  development  of  the  disease,  and  cases  have  come  under  one's 
notice  in  which  a  hsematoma  later  became  converted  into  a  tuberculous 
abscess. 

Pathology 

With  the  exception  of  mastoid  disease,  which  is  really  not  a  true  form 

of  original  bone  tubercle,  the  frontal 
bone  is  the  most  common  situation  of 
the  disease.  The  infection  is  blood- 
borne,  and  it  develops  as  a  typical 
tuberculous  osteomyelitis  in  the  diploe 
of  the  bone.  As  caseation  and  pus 
formation  occur  the  disease  spreads  to 
beneath  the  pericranium,  and  there 
it  forms  a  localised  cold  abscess.  It  is 
exceptional  for  the  infection  to  extend 
deeply  and  to  form  an  extra  -  dural 
collection,  although  the  author  has 
observed  a  case  in  which  the  infection 
had  extended  from  the  deep  surface 
of  the  skull  bone  through  the  mem- 
branes of  the  brain  and  involved  the 
cerebral  tissue.  The  disease  extends 
rapidly  throughout  the  bone.  The 
small  area  of  cancellous  space  and  the 
density  of  the  compact  bone  upon 
each  side  renders  the  formation  of  extensive  sequestra  likely. 


Fig.  159.  — Tuberculous  disease  of  the 
frontal  bone  with  abscess  formation 
(left  side). 


Clinical  Features 

There  are  usually  very  few  clinical  features.  Pain  may  be  persistently 
complained  of  at  the  site  of  the  disease,  and  it  may  be  noticed  that  the  pain 
considerably  lessens  when  the  surface  abscess  appears,  apparently  as  the 
result  of  the  lowered  tension  within  the  bone.  In  the  absence  of  pain, 
swelling  is  the  feature  noticed ;  it  is  a  subpericranial  collection  of  pus,  and 


TUBERCULOUS  DISEASE  OF  THE  SKULL  BONES  329 

while,  at  first,  its  position  indicates  the  situation  of  the  osseous  disease,  it 
gradually  extends  beneath  the  pericranium  over  the  siu:face  of  the  bone. 
As  long  as  it  remains  beneath  the  pericranium  its  distribution  is  limited  by 
the  line  of  the  sutures.  If  treatment  of  the  condition  is  neglected  the  abscess 
pierces  the  pericranium,  becomes  superficial,  and  ultimately  forms  a  sinus 
to  the  surface.  A  mixed  infection  may  thus  gain  admission,  and  when  it 
does  the  disease  makes  more  rapid  progress,  and  there  is  extensive  sequestrum 
formation.  In  the  event  of  the  disease  involving  the  intracranial  tissues 
the  features  of  cerebral  compression  appear. 

Prognosis 

A  guarded  and  somewhat  unfavourable  prognosis  should  be  given. 
The  disease  is  an  indication  of  a  wide  dissemination  of  the  infection,  and 
sooner  or  later  it  is  complicated  by  development  of  the  process  in  other 
situations — the  meninges. 

Treatment 

In  the  early  stages  of  the  disease  operation  offers  the  best  chance  of 
cure,  and  therefore  it  is  not  ad\'isable  to  waste  time  by  such  conservative 
measiu'es  as  aspiration  of  the  abscess.  The  operation  consists  in  making 
a  horseshoe-shaped  incision  a  little  beyond  the  upper  three-fourths  of  the 
limit  of  the  swelling.  The  incision  penetrates  to  the  bone,  and  a  flap  includ- 
ing soft  tissues  and  pericranium  are  dissected  off  the  bone.  The  walls  of  the 
abscess  are  exposed  on  the  deep  surface  of  the  flap  and  on  the  bone ;  these  are 
thoroughly  scraped  with  a  sharp  spoon.  A  disc  of  bone  is  removed  from 
the  diseased  area  with  a  trephine,  and  with  rongeur  forceps  the  surrounding 
skull  is  cut  away  until  the  healthy  bone  is  reached.  Great  care  should  be 
taken  to  avoid  injuring  the  dura.  When  the  diseased  bone  has  been 
thoroughly  removed  and  all  tuberculous  tissue  scraped  oft'  the  surface  of  the 
dura,  the  skin  flap  is  sutured  back  into  position. 

After-treatment. — No  local  form  of  after-treatment  is  necessary,  but 
every  attention  should  be  paid  to  an  improvement  of  the  patient's  general 
condition. 

BIBLIOGRAPHY 

Pa(ifs.     "  Osteite  tubcrculeuso  dti  crane,"  Lyon  vied.,  1008,  cxi.  51-53. 

TouRNEAUX,  .1.  P.,  and  UuciiNO,  P.     "  Un  Cas  d'ostt'ile  tuborciilouso  du  crane,"  Toulouse 

med.,  li)lU,  2"  ser.  .\ii.  187. 
Seii.iian.  KiiANfOiSE.     Conlribulioii  a  t'elude  de  la  lubercitloae  de  la  i-oule  du  crane,  Toulouse, 

1011,  70  pages. 


330 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


TUBERCULOUS  DISEASE  OF  THE  LOWER  JAW 

Etiology 

Tuberculous  disease  of  the  lower  jaw  is  more  common  than  is  perhaps 
imagined.  It  occurs  very  often  at  that  period  of  life  when  the  second 
dentition  is  making  its  appearance.  It  frequently  attacks  the  children  of 
phthisical  patients,  and  for  this  reason  the  human  bacillus  is  said  to  be  the 
common  type  of  organism  present. 


Pathology 

Stockmann  has  shown  that  phosphorous  necrosis  of  the  jaw  has  an 
underlying  element  of  tuberculous  disease,  and  that  the  infection  of  the 

latter  disease  probably  occurs 
through  the  medium  of  a  de- 
cayed tooth.  But  the  type 
of  tuberculous  jaw  which  one 
meets  with  in  children  owes  its 
infection  to  another  source. 
The  organisms  are  carried  into 
the  jaw  by  the  blood  stream. 
They  may  settle  in  the  ramus 
of  the  jaw  where  there  are  no 
teeth,  but  more  frequently  they 
are  deposited  in  the  body  of 
the  jaw,  in  relation  to  the  fine 
blood-vessels  entering  the  roots 
of  the  teeth.  As  the  disease 
develops  a  quantity  of  tuber- 
culous granulation  tissue  de- 
velops around  the  root  and 
the  tooth  becomes  loose.  The 
disease  extends  further  into  the 
jaw  and  invades  the  cancellous  bone  of  the  interior.  The  periosteum, 
both  inside  and  outside,  becomes  thickened  from  an  irritative  deposit  of  new 
bone.  In  extensive  disease  a  cold  abscess  may  form  upon  the  outer  surface 
of  the  bone.  Owing  to  the  comparative  thinness  of  the  ramus  it  is  more 
likely  to  occur  in  this  situation  than  in  the  body  of  the  bone. 


Flo.  160, — Tulierciilous  disease  of  the  ramus  of  the  left 
lower  jaw. 


PTjATE   IJ.— TUHKUcuLons  Diska.se  ov  thk  LowEii  Jaw. 

(/,  TuliiTiMilou.s  clisra.'iu  of  tln'  liody  of  tlif  lower  jaw.  b,  Tulu'i'culou.s  clisuiLsf  of  tlu'  liody  of  tlu'  jaw  nml 
spn-udiiiK  into  tlit-  raimis.  c,  The  lowi-r  jaw  witli  tlie  tootli  in  situ.  Ttii;  ilisca.su  lia.s  oiigiiialisl  at  llic  root  of 
till'  tooth,  and  it  lias  begun  to  s|irfnd  over  the  surface  of  the  jaw.  il,  Tuljcrculous  disease  ori^tiiiatiiiK  at  the  root 
<if  a  tootli. 


TUBERCULOUS  DISEASE  OF  LOWER  JAW  331 

Clinical  Features 

Pain. — Children  affected  with  this  disease  complain  of  pain  in  the  jaw. 
To  some  extent  it  is  limited,  but  pain  is  also  complained  of  which  shoots 
along  the  distribution  of  the  inferior  dental  nerve. 

Loose  Teeth. — Loosening  of  the  teeth  is  a  characteristic  feature.  The 
infiltration  of  the  disease  within  the  tooth  socket  is  responsible.  Sometimes 
the  tooth  may  be  pulled  out  from  the  jaw  without  any  pain.  It  is  further 
noticeable  that  the  cavity  from  which  the  tooth  is  withdrawn  does  not 
bleed. 

Swelling. — The  thickening  of  the  jaw  is  the  result  of  the  deposit  of  new 
subperiosteal  bone,  and  the  deposit  is  secondary  to  the  irritative  process 
in  the  interior"  of  the  bone.  It  should  be  noticed  that  the  thickening  is 
present  upon  both  surfaces  of  the  jaw,  in  contradistinction  to  a  simple 
periostitis  which  is  often  limited  to  the  outer  table  of  the  bone. 

Abscess  Formation. — The  bony  swelling  may  be  suddenly  accentuated  by 
the  development  of  a  cold  abscess.  The  abscess  may  make  its  way  to  the 
surface  through  the  skin  or  through  the  mucous  membrane  into  the  mouth. 
When  the  abscess  opens  into  the  mouth  the  gravity  of  the  disease  is  greatly 
increased  by  the  tendency  which  there  is  to  the  development  of  laryngeal, 
bronchial,  or  mesenteric  tubercle. 

Glandular  Enlargement. — It  is  common  to  find  the  submaxillary  and  sub- 
mental lymphatic  glands  infected  with  tubercle  secondary  to  disease  of  the 
jaw. 

Diagnosis 

There  may  be  considerable  difficulty  in  coming  to  a  certain  diagnosis. 
A  general  anaesthetic  may  require  to  be  given  to  ensure  a  thorough  examina- 
tion of  the  part.  Importance  will,  of  course,  be  attached  to  the  presence  of 
tubercle  in  other  situations.  There  are  two  conditions  which  are  apt  to 
be  mistaken  for  tuberculous  disease,  namely,  cystic  disease  of  the  jaw  and 
simple  inflammatory  periostitis. 

Cystic  disease  is  excluded  by  the  facts  that  it  develops  usually  between 
twenty  and  forty,  that  it  develops  exceedingly  slowly,  gradually  di.stending 
the  bone,  and  that  there  is  no  tendency  to  tiie  development  of  super- 
ficial abscesses.  Any  doubt  which  may  exist  is  cleared  away  by  X-ray 
examination. 

Simple  periosiitis  has  usually  an  acute  or  subacute  history  suliicient  to 
demonstrate  the  nature  of  the  infection. 


Prognosis 

If  the  disease  is  early  recognised  and  completely  removed,  the  pro- 
gnosis is  good.  The  grave  element  appears  wlieii  sinuses  0[)en  into  the 
mouth. 


332 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


Treatment 


Fui.  161.- 


-Tuberculous  disease  of  the  left 
malar  bone. 


WTiile  every  attention  should  be  given  to  the  improvement  of  the 

patient's  general  condition,  there  are  no  conservative  means  of  treatment 

which  can  be  adopted.  It  is  well  to 
observe  any  improvement  which  arises 
from  the  removal  of  decayed  and 
loosened  teeth.  It  remains  to  discuss 
the  operative  treatment,  and  it  should 
be  insisted  that  this  is  carried  out  as 
early  as  possible. 

Operation. — The  preliminary  should 
be  observed  of  having, the  interior  of 
the  mouth  in  as  healthy  a  condition  as 
possible  ;  a  tooth  brush  is  thoroughly 
used  and  all  decayed  teeth  are  re- 
moved. The  operation  consists  in  a 
subperiosteal  resection  of  the  diseased 
bone.  The  incision  begins  in  front  of 
the  lobule  of  the  ear,  it  passes  verti- 
cally downwards  along  the  posterior 
margin  of  the  ramus,  turns  round  the 
angle  and  runs  forwards  as  far  as  is 

necessary,  paraOel  to  and  a  little  below  the  lower  margin  of  the  jaw.     The 

upper  part  of  the  incision  is  so  superficial  as  not  to  injure  the  facial  nerve, 

the  remainder  of  the  incision  passes  on 

to  the  bone.     The  facial  artery  is  divided 

and  clamped.     The  periosteum  is  incised 

along  the  lower  margin  of  the  jaw  and 

along  the  posterior  border  of  the  ramus. 

With   a   broad    periosteal    elevator,    the 

periosteum  and  the  masse ter  are  separated 

off  the  outer  surface  of  the  ramus  and 

forwards  to  beyond  the  disease.     In  the 

same  way  the  periosteum  and  the  internal 

pterygoid  are  separated  from  the  inner 

surface   of  the  jaw.      The  bone  is  now 

removed,  according  to  the  position  of  the 

disease.     If  the  disease  is  limited  to  the 

body,   the    jaw    is    divided   in   front   of 

and  behind  the  disease  and  the  segment 

removed.     If  the  ramus  is  involved  the 

bone  is  divided  in  front  with  saw  or  bone  forceps,  and  the  posterior  part 

is  wrenched  away  subperiosteally  from  the  temporo-maxillary  joint.     The 

end  of  the  torn  inferior  dental  artery  is  ligatured.     The  periosteal  space  is 

partly  closed  off  with  interrupted  catgut  sutures,  a  drain  is  inserted,  and  the 


Fig.  162.- 


-Tuberculoiis  disease  of  botb 
malar  bones. 


UPPER  JAW  AND  MALAR  BONE  333 

skin  wound  closed.  When  the  disease  involves  the  greater  part  of  the 
horizontal  ramus,  tracheotomy  should  be  performed  before  the  bone  is 
removed,  as  after  removal  of  the  bone  the  loss  of  attachment  of  the  tongue 
muscles  may  produce  a  falling  back  of  that  organ  and  asphyxia. 

After-treatment. — It  is  essential  to  keep  the  mouth  as  sweet  as  possible 
after  operation  ;  a  mild  antiseptic  mouth  wash  is  employed. 


TUBERCULOUS  DISEASE  OF  THE  UPPER  JAW  AND 

MALAR  BONE 

The  disease  originates  in  the  cancellous  tissue  around  the  suture  uniting 
the  malar  bone  and  the  superior  maxilla.  Abscess  formation  readily  occurs  ; 
the  abscess  may  appear  upon  the  front  of  the  face,  in  the  zygomatic  fossa, 
or  in  the  floor  of  the  orbit.  The  abscess  soon  perforates  on  to  the  surface, 
and  there  is  a  sinus.     Sequestrum  formation  is  common. 

Pain. — Abscess  formation  and  the  presence  of  a  persistent  sinus  are, 
practically  speaking,  the  only  clinical  features. 

As  in  disease  of  the  lower  jaw  conservative  treatment  is  of  little  avail, 
therefore  operative  measures  ought  to  be  adopted  at  an  early  stage.      The 


Vu:.  1(>3. — TiiWrculnia  .ii  ta-.i     ;  :. ,.■.•-  '.      .i  .,...     .ml  left  iiiiiliir  buiif. 

best  incision  for  the  e.xposure  of  the  part  is  one  which  begins  a  little  bi'low 
the  middle  of  the  infraorbital  margin,  and  pa.sses  downwards  and  outwards 
over  the  malar  bone  for  the  necessar}'  distance.  The  incision  lias  the  double 
advantage  of  avoiding  the  braiiclies  of  the  facial  nerve  and  of  leaving  a  .scar 
which  is  concealed  in  tin-  natural  folds  of  the  skin.     The  ab.scess  cavitv  is 


334 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


cleaned  out,  the  periosteum  is  separated  from  the  bone  and  the  diseased 
focus  removed. 


Fig.  164. — Central  tuberculous  disease  of  the  patella.     (Dr.  Kirk's  case.) 


TUBERCULOSIS   OF  THE   RIBS 

The  ribs  may  be  infected  -with  a  primary  tuberculous  osteomyelitis, 
or  they  may  become  involved  secondary  to  tuberculous  disease  of  a  neigh- 
bouring part,  such  as  the  pleura,  in  which  case  the  disease  begins  as  a  peri- 
ostitis. 

The  clinical  features  are  indefinite,  pain  is  often  complained  of  before 
the  appearance  of  an  abscess.  Early  abscess  formation  is  characteristic.  It 
may  be  situated  over  the  site  of  the  bone  focus  ;  sometimes  it  makes  its  way 
along  the  line  of  nerves,  blood-vessels,  or  tissue-planes,  and  appears  at  a 
considerable  distance  from  the  original  disease.  From  a  focus  in  the  posterior 
extremity  of  the  rib  the  pus  may  burrow  along  the  line  of  the  intercostal 
vessels,  and  appear  in  the  mid-axillary  line  or  at  the  side  of  the  sternum. 
When  the  disease  is  situated  at  the  costo-chondral  junction  a  secondary 
abscess  may  gravitate  downwards,  enter  the  sheath  of  the  rectus,  and  filter 
down  the  whole  length  of  the  abdominal  wall.  It  is  exceptional,  but  it 
sometimes  happens,  that  the  abscess  collects  between  the  pleura  and  the 
chest  wall. 

The  treatment  consists  in  complete  and  early  excision  of  the  diseased 
rib.  A  horseshoe-shaped  incision  is  preferable  to  one  in  the  line  of  the 
rib,  as  it  gives  more  complete  access.  The  convexity  of  the  incision  is 
directed  downwards,  and  the  flap  is  dissected  upwards  off  the  chest  wall. 
If  an  underlying  abscess  is  exposed,  it  is  completely  dissected  away.  The 
ribs  are  carefully  examined  for  signs  of  disease,  it  may  be  a  periosteal  thicken- 
ing, it  may  be  a  sinus  leading  into  the  bone.     The  diseased  bone  is  resected 


TUBERCULOSIS  OF  THE  RIBS  335 

subperiosteally,  and  any  disease  in  the  periosteum  is  dissected  out.  The 
flap  is  sutured  back  into  position  with  or  without  drainage. 

When  the  abscess  has  travelled  some  distance  before  becoming  super- 
ficial enough  to  be  recognised,  it  may  be  difficult  to  decide  on  the  situation 
from  which  the  infection  originated.  In  such  circumstances  it  is  proper 
to  open  the  abscess,  and  by  following  the  track  taken  by  the  pus,  to  expose, 
if  possible,  the  original  focus. 

BIBLIOGRAPHY 

Rowlands,  R.  P.     "The  Treatment  of  Caries  of  the  Ribs,"  Guys  Hasp.  Rep.,  London, 

1907,  Ixi.  245-247. 

Barbakin,  p.     "  Un  Cas  de  tuberculose  costale  traite  par  le  radium,"  Paris  chirurg.,  1911, 

iii.  433-435. 
Gross.     "  Spina  Ventosa  Costal,"  Prov.  tiied.,  Paris,  1912,  xxiii.  515. 

Special  Regions  ' 

Patella. 

GoLDiNG  Bird.  "  Tubercle  of  the  Patella,"  Guy's  Hasp.  Gaz.,  London,  1907,  xxi.  465-468. 
Murphy,  J.  B.  "  Tuberculosis  of  the  Patella,"  Surg.  Gyr>ec.  and  Obstelr.,  1908,  vi.  262-273. 
KiRMissoN.     "  La  Tuberculose  primitive  de  la  i-otule,"  Bev.  gen.  de  din.  et  de  therap.,  Paris, 

1908,  xxii.  773. 

Bourgeois,  Paul.     "  Contribution  a  I'^tude  de  la  tuberculose  de  la  rotule,"  Paris,  1908. 

Pubes. 

MoiGNET,  fiiaiLE.     Contribution  &  I'etude  de  Vossitis  tuberc.  du  pubis,  Paris,  1911,  Journ.  etc. 
Circ,  48  pages. 

Ischium.. 

Zellmeyer.     "  fitudes  cliniques  de  la  tuberculose  de  I'ischion,"  Rev.  internal,  de  la  tuberc, 
Paris,  1909,  xv.  101-104. 

Mastoid. 

Mackenzie,  D.     "  Tuberculous  Disease  of  the  Petrous  or  Mastoid  Process,"  Clin.  J.,  London, 
1910-11,  xxxvii.  190. 

Malar  Bone. 

LiPRAT,  J.  H.  (i.     Tuberculose  de  Vos  malaire,  Paris,  1908. 

Palate. 

DiTTRiBU.     '■  Tuberculosis  mucosae  jjalati  duri,"  J.  Cutan.  Dis.  incl.  Syphilis,  New  York, 
1910,  xxviii.  300. 

Sternum. 

Jacques,  R.     "  De  la  tuberculose  du  sternum,"  Rev.   inlernat.  de  la  tuberc,  Paris,   1910, 

xviii.  408-414. 
Batut,  L.     "  Affections   des  os :   tuberculose   du   sternum,"    Bull.   Soc.   Med.  Chir.  de  la 

Drome,  Valence,  1911,  xii.  186. 
MoRK.STON.     "  Tumcur   blanche  sterno-claviculaire  traitee   par   Ics   injections   do   parniol," 

Bull,  et  mem.  Soc.  de  Chir.  de  Paris,  1912,  M.S.,  xxxviii.  1462-1464. 


GENERAL    INDEX 


Abduction  in  hip-joint  disease,  216 
Abscess,  dorsal,  122 
iliac,  197 

in  Petit's  triangle,  196 
intra-articular,  49 
intra-pelvic,  325 
lumbar,  195 
periarticular,  49 
prevertebral,  124 

thoracic,  193 
retropharyngeal,  122 
supra-clavicular,  193 
Abscess  formation  in  bone  tuberculosis,  45 
hip-joint  disease,  217 

treatment  of,  240 
joint  tuberculosis,  49 
Pott's  disease,  120 

examination  for  presence  of,  141 
symptoms  dependent  on,  129 
treatment  of,  191 
sacro-iliac  disease,  325 
tuberculosis  of  the  lower  jaw,  331 
Abscesses,  in  tuberculous  disease  of  the  knee- 
joint,  treatment  of,  271 
shoulder-joint,  306 
wrist-joint,  321 
originating  in  the  cervical  spine,  120 
dorsal  spine,  122 
lumbar  spine,  124 
treatment  of  cold,  76 
Adam's  operation  for  hip-joint  disease,  238 
Adduction  in  hip-joint  disease,  216 
Administration    of   tuberculin,   methods    of, 

87 
Ago  in  bono  tuberculosis,  50 
hip-joint  disease,  204 
Pott's  disease,  1 1 1 
Alderman's  gait  in  Pott's  disease,  132 
Alexan<lra  Hip  Hospital,  242 
AUyl  sulphide   treatment   of    bono   tubercu- 
losis, 85 
Alterations  in  buny  outlines  in  joint   tuber- 
culosis, 49 
position  in  joint  tuberculosis,  47 
use  in  joint  tuberculosis,  46 
Ambulatory  hiji  splint,  choice  of,  234 
treatment  of  hip-joint  disease,  228 
Pott's  disease,  163,  186 

indications  for,  164 
sacroiliac  disease,  326 
tuberculous   disease    of    the    knee-joint, 
265 


Amphiarthrodial  joint,  34 
Amputation  in  ankle-joint  disease,  290 
hand  and  foot  tuberculosis,  302 
hip-joint  disease,  253 
joint  tuberculosis,  106 
knee-joint  disease,  277 
Anatomy  of  ankle-joint,  281 
bone,  microscopic,  13 

normal,  11 
elbow-joint,  313 
hip-joint,  204 
joints,  normal,  34 
knee-joint,  259 
sacro-iliac  joint,  324 
shoulder-joint,  304 
tarsus,  291 
wrist-joint,  319 
Ankle-joint,  anatomy  of,  281 
excision  of,  287 
tuberculous  disease  of,  281 
diagnosis  of,  284 
etiology  of,  281 
pathology  of,  281 
physical  signs  of,  282 
prognosis  of,  285 
symptoms  of,  282 
treatment  of,  285 
Ankylosis  of  patella  to  femur,  278 
Apparatus  for  X-ray  examination  of  tuber- 
culous bones,  38 
Appearance  in  hip-joint  disease,  210 

Pott's  disease,  132 
Arthrectomy,  106 

Arthroplasty     in     ankylosis     of     hip  -  joint, 
250 
knee-joint,  277 
Arthrotomy,  105 
Articular  cartilage,  anatomy  of,  14 

in  tuberculosis  of  joints,  36 
Aspiration  of  abscess   in   hip-joint   disease, 
241 
cold  abscesses,  77 

with  injection  of  medicaments,  78 
Aatrogalus,  operation  for  tuberculous  disease 

of,  294 
Atrophic  tubercle.  X-ray  appearance,  61 

tuberculous  lesion,  pathology  of,  25 
Atrophv  in  tuberculosis  of  the  elbow-joint, 

314 
Attitude  in  Pott's  disease,  130 

sacro-iliao  disease,  325 
Autogonouu  luburculina,  80 

337  22 


338 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


Barton's  operation  in  hip-joint  disease,  239 
Beck's  paste,  82,  96 
Bed-frame,  Bradford,  153 

Fisher's,  151 
Bed   specially   adapted   for    recumbency   in 

Pott's  disease,  149 
Beraneck's  tuberculin,  85 
Berck  hospital  for  surgical  tuberculosis,  67, 

157 
BiUroth  splint,  269 

Bismuth     injection      of      sinuses,     contra- 
indications for,  82 

iodoform   paste  in  the  treatment  of  cold 
abscesses,  80 
Blood-supply  of  bones,  11 

hip-joint,  205 

joints,  35 

vertebrae,  113 
Blood-vessel  changes  in  tuberculosis  of  bone, 
21 

joints,  38 
"  Boarding  "  of  the  spme  in  Pott's  disease, 

135 
Body  conditions  in  Pott's  disease,  132 
Bone,  atrophic  tuberculosis  of,  25 

blood-vessel  changes  m  tuberculosis  of,  21 

diagnosis  of  tuberculosis  of,  50 

encysted  tuberculosis  of,  22 

gross    pathological    varieties    of    tubercu- 
losis of,  22 

hypertrophic  tuberculosis  of,  26 

infiltratmg  tuberculosis  of,  23 

lamella  changes  in  tuberculosis  of,  20 

location  of  lesion  in  tuberculosis  of,  30 

marrow  changes  in  tuberculosis  of,  19 

method  of  healing  in  tuberculosis  of,  29 

microscopic  anatomy  of,  13 

normal  anatomy  of,  11 

normal  X-ray  appearance  of,  58 

pathology  of  tuberculosis  of,  11 

periosteal  changes  in  tuberculosis  of,  21 

sequelae  of  tuberculosis  of,  29 

tuberculous  disease  of  {vide  Tuberculous) 

X-ray  appearance  of  normal  bone,  58 
Bone  tuberculosis,  clinical  features  of,  44 

operative  treatment  of,  92 

prognosis  in,  64 

treatment  of,  65 
Bones,  blood-supply  of,  11 

frequency  of  affection  of  various,  10 

of  the  hand  and  foot,  tuberculous  disease 
of,  297 

routes  of  infection  of,  7 
Bovine  tuberculin,  85 
Braces  in  Pott's  disease,  metal,  170 
Bradford  bed-frame,  153 

hip  splint,  231 
Briant's  triangle,  213 
Burns'  space,  121 

Calcification  of  the  original  follicle,  18 
Calliper  splint,  267 

Calmette's  ophthalmo-tuberculin  reaction,  51 
Calot's  solution  in  the  treatment  of  sinuses, 
83 


Caries  carnosa,  25 
sicca,  25 

of  the  shoulder- joint,  307 
Caseation  of  the  original  follicle,  18 
Celluloid  for  bone  fixation,  71 

jackets  in  Pott's  disease,  176 
Cervical  fascia,  arrangement  of  deep,  120 
Cervical  Pott's  disease,  143 
upper,  143 
spine,  139 
Cervico-dorsal  Pott's  disease,  143 
Changes     associated     with     the     original 

tubercle,  19 
Channels  of  entry  of  bacilli  into  the  bod3',  6 
Circus  vasculosus,  30 
Climatic  conditions  in  surgical  tuberculosis, 

67 
Clinical  evidences  of  joint  tuberculosis,  41 
Clinical  features   of   tuberculous    disease  of 
bone,  44 
joints,  46 
lower  jaw,  331 
sacro-iliac  joint,  325 
skull  bones,  328 
tarsus,  291 
wrist-joint,  320 
Complications   in   hip  -  joint    disease,   treat- 
ment of,  240 
Compression   paraplegia    in    Pott's    disease, 

117 
Congenital  tuberculosis,  9 
Conservative   treatment   of   cold    abscesses, 
77 
tuberculous  disease  of  joints,  100 
knee-jomt,  264,  268 
sacro-iliac  joint,  326 
surgical,  70 
wrist-joint,  321 
Convalescent  hip  splint,  233 

treatment  of  hip-joint  disease,  234 
Correction   of   deformities   in   hip-joint   dis- 
ease, gradual,  236 
operative,  238 
rapid,  238 
Pott's  disease,  methods  of,  187 
Costo-transversectomy,  194,  198 
Counter  -  irritation    in    treatment    of    bone 
cUsease,  76 
joint  tuberculosis,  102 
Cranium    in    Pott's    disease,    compensatory 

changes  in,  142 
Creosote    iodoform    injections    in    cold    ab- 
scesses, 79 
Cuirass,  Thomas',  176 
Culture  test,  the  original,  4 

the  special,  5 
Cupping,  hypersemia  by  means  of  di-y,  75 
Curetting  operations  in  hip-joint  disease,  205 
joint  tuberculosis,  105 

Dane  hip  splint,  232 
Da  vies'  head  support,  184 
.  quadrilateral  brace,  172 
Deformity  in  tuberculous  disease   of  ankle- 
joint,  treatment  of,  287 


GENERAL  INDEX 


339 


Deformity  in  tuberculous  disease  of  elbow- 
joint,  313 
hip-jomt,  treatment  of,  236 
joints,  correction  of,  106 
knee-joint,  261 

correction  of,  209 
spine,  abolition  of,  187 
gradual  correction  of,  189 
operation  for,  187 
permanent  record  of,  137 
wrist-joint,  320 
Degeneration  of  the  original  follicle,  central 

cystic,  18 
Dense  bone,  method  of  formation  of,  21 
Deny's  tuberculin,  85 

Diagnosis  of   tuberculous  disease  of  ankle- 
joint,  284 
bone,  50 

differential,  53 
elbow-joint,  314 
hip-joint,  218 
jaw  (lower),  331 
joints,  54 

differential,  55 
knee-joint,  263 

long  bones  of  hand  and  foot,  299 
sacro-iliae  joint,  325 
shoulder-joint,  307 
spine,  143 

differential,  144' 
tarsus,  292 
wrist-joint,  321 
Diaphysis,  anatomy  of,  15 
Diaphysitis,  33 
Diarthrodinl  joints,  34 
Diet  in  surgical  tuberculosis,  68 
Differential  Diagnosis  {vide  under  Diagnosis) 

tests  between  human  and  bovine  bacilli,  4 
Dislocation  of  the  hip,  operative,  252 
Dorsal  spine,  movements  of,  140 
Dorsal  and  dorso-lvimbar  Pott's  disease,  143 
Drugs  in  surgical  tuberculosis,  69 

Elbow-joint,  anatomy  of,  312 
excision  of,  315 
tuberculous  disease  of,  312 

diagnosis  of,  314 

etiology  of,  312 

pathology  of,  312 

physical  signs  of,  313 

prognosis  of,  314 

symptoms  of,  313 

treatment  of,  314 
Empyaima  of  joint,  49 

tuberculous,  124 
Encysted  tuberculous  lesion,  22 
Entry  of  bacilli  into  the  body,  channels  of,  6 
Epiphyseal  cartilage,  anatomy  of,  14 
Epiphysis,  anatomy  of,  15 
Etiology  of  tuberculosis,  3 

tuberculous  disease  of  the  anUle-joint,  281 

elbow-joint,  312 

hip-joint,  204 

jaw  (lower),  330 

knee-joint,  25S 


Etiology  of  tuberculous  disease  of  the  sacro  - 
iliac  joint,  324 

shoulder-joint,  304 

skiiU  bones,  328 

spine.  111 

tarsus,  290 

wrist-joint,  319 
Examination  of   patient   in   Pott's   disease, 

129 
tuberculous    disease    of    the    knee  -  joint, 

methods  of,  263 
Excision,  106 

of  ankle-joint,  287 

after  treatment  of,  289 

results  of,  289 
elbow-joint,  Kocher's,  317 

posterior,  316 

results  of,  318 
hip-joint,  after  results  of,  252 

anterior,  243 

external,  245 

posterior,  246 
knee-joint,  271 

results  of,  276 
shoulder-joint,  anterior,  308 

posterior,  310 
wrist-joint,  322 
Extension  treatment   of   joint    tuberculosis, 

101 
in  tuberculous  disease  of  the   knee-joint, 

285 
Extract  tuberculin,  preparation  of,  86 

Family  history  in  bone  tuberculosis,  50 
"  Fibrillation  "  of  the  cartilage,  3(5 
Fibrosis    surroundmg    the    origmal    follicle, 

18 
Fillet  plaster  jacket,  167 
Fisher  bed-frame,  151 
Fixation  treatment  by  celluloid,  71 

metal,  72 

plaster  of  Paris,  70 

wood,  72 
of  tuberculous  disease  of  ankle-joint,  285 

elbow-joint,  314 

knee-joint,  265 

joint,'  100 

wrist-joint,  321 
Flexion  in  hip-joint  disease,  215 
"  Focal  reaction  "  test,  52 
Follicle,  changes  in  the  original,  18 
Frequency  of  affection  of  the  various  bones,  10 

joints,  10 
hip-joint  disease,  204 

Gait  in   tuberculous  disease   of   the   ankle- 
joint,  283 

sacro-iliae  joint,  325 

spine,  130 
Gant's  operation  in  hip-joint  disease,  240 
Gouvain's  back-door  splint,  158 

posterior  suspensory,  159 

spinal  board,  157 

wheelbarrow  splint,  159 


340 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


General   causes,   predisposition   to  tubercu- 
losis by,  10 
features  in  bone  tuberculosis,  45 

joint  tuberculosis,  50 
health  in  hip-joint  disease,  210 
treatment    of   tuberculous  disease   of    the 
ankle-joint,  285 
knee-joint,  264 
Genuclast,  270 
Giant  cell  formation,  18 
Gibbosity  in  Pott's  disease,  115 

operative  treatment  of,  189 
Glandular    enlargement    in    tuberculosis    of 

the  lower  jaw,  331 
Gluteal  fold  in  hip-joint  disease,  212 
Goldthwaite  head  support,  183 
Gouging  in  bone  tuberculosis,  95 


Halter  sling,  314 
Hamilton's  splint,  double,  326 
Hand  and  foot,  tuberculous  disease  of  long 
bones  of,  297 

diagnosis  of,  299 

pathology  of,  297 

physical  signs  of,  298 

prognosis  of,  300 

symptoms  of,  298 

treatment  of,  300 
Haversian  gland,  205 
Head  supports  in  Pott's  disease,  180 
Healing  in  bone  tuberculosis,  methods  of,  29 

joint  tuberculosis,  methods  of,  42 
Heart  in  Pott's  disease,  changes  in,  118 

examination  of,  142 
Heredity  in  Pott's  disease,  112 

predisposition  to  tuberculosis  by,  9 
Hip-joint,  anatomy  of,  204 

blood-supply  of,  205 

excision  of,  243 

after  results  of,  252 

operative  dislocation  of,  252 
Hip-joint  disease,  204 

diagnosis  of,  218 

etiology  of,  204 

pathology  of,  204 

physical  examination  in,  210 

prognosis  in,  220 

symptoms  of,  208 

treatment  of,  221 

X-ray  examination  in,  218 
Histogenesis  of  the  original  tubercle,  16 
Histology  of  the  original  tubercle,  16 
History  in  bone  tuberculosis,  family,  50 

milk,  50 
Howship's  lacunae,  20 
Hydrops,  tuberculous,  41 
Hygienic  home  conditions,  66 

hospital  conditions,  66 
Hyperemia,  active,  73 

mixed,  75 

passive,  74 

suction    75 
Hyperaemio  treatment  of  joint  tuberculosis, 
103 


Hypertrophic    tubercle.   X-ray    appearance 
of,  61 
tuberculous  lesion,  pathology  of,  26 

Iliac  abscess,  197 

Incision  of  abscess  in  hip-joint  disease,  241 

cold  abscess  with  drainage,  81 
without  drainage,  80 
Index,  tuberculo-opsonic,  52 
Infection  in  hip  -  joint   disease,  method  of, 
206 

of  bones  and  joints,  routes  of,  7 
Infiltrating    tubercle.   X-ray  appearance  of, 
60 

tuberculous  lesion,  23 
Ijifillration  grise,  23 

lie  de  vin,  23 

puriforme,  23 
Inguinal  glands  in  hip-joint  cUsease,  212 
Injection  of  sinuses  with  medicaments,  82 
Injections  in  the  treatment  of  joint  tubercu- 
losis, 103 

Lannelongue's  sclerogenic,  269 
Injury  in  Pott's  disease,  history  of.  111 

predisposition   to   tuberculosis   by  reason 
of,  9 
Inoculation  test,  5 

Iodine  injections  in  cold  abscesses,  79,  80 
Iodoform  injections  in  cold  abscesses,  78  ' 

Jaw,    tuberculous    disease    of    lower    (vide 
also  Tuberculous  Disease),  330 
upper,  333 
Joint,  blood-supply  of  a.  35 

diagnosis  of  tuberculous  disease  of  a,  55 
structures  entering  into  formation  of  a, 

34 
tuberculous  disease    of    (vide    Tubercu- 
lous) 
X-ray  appearance  of  a  normal,  61 
movements  in  hip-joint  disease,  214 
transplantation,  278 
tuberculosis,  clinical  features  of,  46 
diagnosis  of,  54 
method  of  healing  in,  42 
prognosis  in,  64 
treatment  of,  100 
varieties  of,  39 

various  clinical   evidences  and  sequelae 
of,  41 
Joints,     changes     in     component    parts    in 
tuberculosis  of,  35 
frequency  of  affection  of  the  various,  10 
normal  anatomy  of,  34 
pathology  of  tuberculous  disease  of,  34 
routes  of  infection  of,  7 
Jones  crab  splint,  286 

operation  in  hip-joint  disease,  240 
splint    for     tuberculous     disease     of     the 
wrist-joint,  321 
Judson  traction  hip  splint,  227 
Jury  mast,  180 

Kingsley's  test  in  hip-jomt  disease,  215 
Knee-joint,  anatomy  of,  258 


GENERAL  INDEX 


341 


Knee-joint,  excision  of,  271 
results  of,  276 
synovectomy,  275 
tuberculous  disease  of,  258 
clinical  features,  259 
diagnosis,  263 
etiolog}',  258 
patholo^jy,  258 
prognosis,  264 
treatment,  26-1 
Knight  spinal  brace,  179 
Koch's  new  tuberculin,  86 

old  tuberculin,  85 
Kochcr's  excision  of  ankle-joint,  287 
elbow-joint,  317 
hip-joint,  246 
Konig's  operation  in  tuberculous  disease  of 

ankle-joint,  289 
Kyphosis  in  Pott's  disease,  114,  134 

Lamellar  changes  in  tuberculous  disease  of 

bone,  20 
Lameness  in  hip-joint  disease,  209 
Laminectomy,  109 

Langenbeck's  excision  of  hip-joint,  245 
Langenbeck's  posterior  excision  of  elbow,  316 
Lannelongue's  sclerogenic  injections,  209 
Lateral  deviations   of    the  spine    in    Pott's 

disease,  116 
Leather  jackets  in  Pott's  disease,  175 
Lesion,  atrophic  tviberculous,  25 

encysted  tuberculous,  22 

hypertrophic  tuberculous,  26 

infiltrating  tuberculous,  23 
Life  prognosis,  64 
Limbs  at  rest  in  hip-joint  disease,  position 

of,  210 
Limp  in  tuberculosis  of  the  ankle-joint,  282 

hip-joint,  211 

sacro-iliac  joint,  325 

tarsus,  291 
Local  prognosis  in  tuberculous  disease,  65 
Localisation  of  Pott's  disease,  1 1 2 
Location  of  lesion  in  tuberculosis  of  bone,  30 
Loop  head  support,  182 
Lordosis,  abnormal  degrees  of  spinal,  136 

in  hip-joint  disease,  210,  212 
Lumbar  abscess,  195 

spine,  movements  of,  140 
Lumbo-sacral  Pott's  disease,  143 

Malar  bone,  tuberculous  disease  of,  333 

Marmorek's  serum,  91 

Marrow,  anatomy  of  bone,  15 

changes  in  tuberculosis  of  bone,  19 

Measurement  of  limb  in  hip-joint  disease,  215 

Mechanical  treatment  of  Pott's  disease,  147 

Medicaments,  injection  of  cold  abscesses  with, 
78 
injection  of  sinuses  with,  82 
treatment  of  tuberculosis  by,  82 

Mehnarto's  s(T\im,  92 

Mcsbe  treatment  of  bone  tubercle,  85 

Metal  splints  for  bone  fixation,  72 

Motaphysis,  30 


Mikulicz's  osteoplastic  resection,  295 
Milk  history  in  bone  tuberculosis,  50 
Minerva  plaster  jacket,  167 
IVUxed  infections  in  surgical  tuberculosis,  89 
Moro's  tuberculin  test,  52 
Morphological  test,  4 
Mosetig  Moorhof's  plug,  95 
Movements   of    joint   in    hip -joint   disease, 
examination  of,  214 
spine,  examination  of,  138 
Murphy's    arthroplastry   in    tuberculosis    of 
the  knee-joint,  277 
glycero-gelatin-formalin  plug,  96 
operation  in  ankylosis  of  the  hip-joint,  251 
Muscular  atrophy  in  tuberculous  disease  of 
the  Ivnee-joint,  261 
wrist-joint,  321 
rigidity    in    tuberculous    disease    of    the 
knee-joint,  260 
spine,  138 
spasm  in  hip-joint  disease,  213 
wasting  in  bone  tuberculosis,  45 
joint  tuberculosis,  49 

Naphthol-camphor    injections     in    cold    ab- 
scesses, 79 
Natural  cure  in  Pott's  disease,  127 
Nelaton's  lines,  213 

operation  in  ankylosis  of  the  hip-joint,  251 
Neuber's  iodoform  starch,  95 
Night  ciies  in  joint  tuberculosis,  47 

hip-joint  tuberculosis,  210 

knee-joint  tuberculosis,  260 

Pott's  disease,  129 
"  Nurse  "  attached  to  a  Thomas  hip-splint, 
225 

Ochsner's  operation  for  tuberculous  disease 

of  ankle-joint,  289 
OUior's  operation,  322 
Operations    in   joint    tuberculosis,  types  of, 

105 
Operative  treatment  of  tuberculous  disease 
of  ankle-joint,  287 
bone,  92 

mdications  for,  93 
preliminaries  to,  94 
types  of,  95 
varieties  of,  94 
hip-joint,  242 
joints,  105 
knee-joint,  271 
sacro-iliac  joint,  326 
shoulder-joint,  308 
wrist-joint,  322 
Ophthalmo-tuberculin  reaction,  51 
Organism  of  tuberculosis,  3 
Os  calcis,  tuberculous  tiiscnso  of,  290 

operation  for,  294 
Osteoporosis,  20 
Osteosclerosis,  20 

Osteotomy     in     ankylosis      of      knee-joint, 
cuneiform,  271 
linear,  270 
hip-joint  disease,  239,  240 


342 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


Pain  in  tuberculous  disease   of   ankle-joint, 
283 
bone,  44 
elbow-joint,  313 
hip-joint,  209 
jaw,  lower,  330 
joints,  47 
knee-joint,  259 
sacro-Uiao  joint,  325 
shoulder-joint,  306 
spine,  128 
tarsus,  291 
wrist-joint,  320 
Palpation  of  joint  in  hip-joint  disease,  212 
Para  -  articular   tuberculosis   of    knee  -  joint, 

operations  for,  277 
Paralysis  in  Pott's  disease,  exammation  for, 
141 
symptoms  dependent  on,  129 
treatment  of,  197 
Paraplegia  in  Pott's    disease,    treatment  of, 

198 
Parker's  excision  of  hip-joint,  243 
Pathological     changes     in    bone    shown    by 

X-rays,  59 
Pathology  of   tuberculous  disease  of   ankle- 
joint,  281 
bone,  11 
elbow-joint,  312 
hip-joint,  204 

summary  of,  207 
jaw,  lower,  330 
joints,  34,  35 
knee-joint,  258 
sacro-iliac  disease,  324 
shoulder- joint,  304 
skull  bones,  328 
spine,  112 
tarsus,  291 
wrist-joint,  319 
Pelvis,  blood-supply  of,  13 

in  Pott's  disease,  changes  in,  119 
compensatoiy  changes  in,  142 
Periosteal    changes   in    tuberculous    disease 

of  bone,  21 
Periosteum,  anatomy  of,  13 
Phelps'  bed  in  Pott's  disease,  156 
box,  160 
hip  splint,  231 
Physical  examination  in    hip-joint    disease, 
210 
diagnosis  of  bone  tuberculosis,  51 

joint  tuberculosis,  54 
signs    in    tuberculous    disease     of    ankle- 
joint,  282 
knee-joint,  259 
shoulder-joint,  305 
spine,  129 
Pirquet's  cutaneous  tuberculin  reaction,   52 
Plaster  bandage  in   treatment    of    hip-jomt 
disease,  224 
bed  in  Pott's  disease,  151 
jacket  applied  by  Brackett's  method,  169 
bj'  Gauvain's  method,  164 
by  Goldthwaite  method,  169 


Plaster  jacket  appUed  by  hammock  frame 
method,  167 
by  Lovett's  method,  169 
in  Pott's  disease,  164 
of  Paris  for  bone  fixation,  70 
splint  in  hip-joint  disease,  238 
Porous  bone,  method  of  formation  of,  21 
Position  in  tuberculosis  of  ankle-joint,  283 

of  lesion  in  bone  tuberculosis,  51 
Pott's    disease    {vide    Spine,    Tuberculous 

Disease  of) 
Predisposition   to   tuberculosis    by   general 
causes,  10 
heredity,  9 
reason  of  injury,  9 
Preparation  of  tuberculin,  mode  of,  86 
Prevertebral  cervical  abscess,  treatment  of, 
192 
thoracic  abscess,  192 
Prognosis  of  spina  ventosa,  300 

tuberculous  disease  of  ankle-joint,  285 
bone  and  joints,  64 
elbow-joint,  314 
hip-joint,  220 
jaw,  lower,  331 
joints,  64 
knee-joint,  264 
sacro-Uiac  joint,  326 
shoulder-joint,  307 
skull  bones,  329 
spine,  146 
wrist-joint,  321 

Kadiograpb,  the  reading  of  a,  58 
Reaction,  cutaneous  tuberculin,  52 

focal  tuberculin,  52 

ophthalmo-tubercuUn,  51 
Recumbency  treatment  of  hip-joint  disease, 
223 

Pott's  disease,  147,  185 
duration  of,  161 
in  special  regions,  160 

sacro-iliac  disease,  326 
Resection  in  bone  tuberculosis,  96 

in  tuberculosis  of  long  bones  of  hand  and 
foot,  301 
Reticulation  of  the  original  follicle,  18 
Retro-pharyngeal  abscess,  treatment  of,  192 
Ribs,  blood-supply  of,  13 

tuberculous  disease  of,  334 
Ridlon's  bridge,  168 

long  traction  splmt,  226 
Rigiditj'  in  joint  tuberculosis,  muscular,  48 

tuberculosis  of  shoulder-joint,  306 
Routes  of  infection  of  bones  and  joints,  7 

Sacro-iliac  disease,  324 

clinical  features  of,  325 

diagnosis,  325 

etiology,  324 

pathology,  324 

prognosis,  326 

treatment,  326 
joint,  anatomy  of,  324 
Sayres"  operation  for  hip-joint  disease,  239 


GENERAL  INDEX 


343 


Schapp's  brace,  172 

Schede's  aseptic  blood  clot,  96 

Scoliosis  in  Pott's  disease,  135 

Sorapiag  in  tuberculous  disease  of  bone,  95 

Self-protection  in  hip-joint  disease,  209 

Senn's  decalcified  bone  chips,  96 

Sensitiveness,  tubercular,  87 

Sequelae  of  bone  tuberculosis,  29 

joint  tuberculosis,  41 
Sequestre  dur,  27 
Sequestres  parcellaires,  24 
Sequestrum  formation,  28 
Serum,  Marmorek's,  91 
Mehnarto's,  92 
Spcngler's,  91 
Sex  in  hip-joint  disease,  204 

Pott's  disease.  111 
Shaffer  hip  splint,  226 
Shortcniag  in  hip-joint  disease,  211,  215 
Shoulder-joint,  anatomy  of,  304 
excision  of,  308 
tuberculous  disease  of,  304 
diagnosis  of,  307 
etiology  of,  304 
pathology  of,  304 
physical  signs  of,  305 
prognosis  of,  307 
symptoms  of,  305 
treatment  of,  307 
Sinus  formation  in  hip-joint  disease,  242 
Sinuses,  hypertemic  treatment  of,  83 

in   tuberculosis  of    the  knee-joint,  treat- 
ment of,  271 
treatment  of  tuberculous,  81 
treatment  by  injection,  82 
Wright's  treatment  of,  84 
Skull  bones,  tuberculous  disease  of,  328 
clinical  features,  328 
etiology,  328 
pathology,  328 
prognosis,  329 
treatment,  329 
Sling,  halter,  314 

Spasm  in  hip-joint  disease,  muscular,  213 
Spengler's  I.K.  serum,  91 
Spica,  long  plaster,  228 

short  plaster,  229 
Spina  ventosa,  30,  297 
Spinal  board,  Gauvain's,  157 
brace.  Knight's,  179 
cord  and  its  membranes  in  Pott's  disease, 

changes  in,  117 
pillow.  Tubby 's,  151 
supports,  1G4 

characteristics  of,  163 
Spine,  tuberculous  disease  of,  111 
diagnosis  of,  143 
etiology  of,  111 
pathology  of,  112 
physical  signs,  129 
prognosis,  146 
symptoms,  127 

treatment  {vide  Treatment  of),  147 
S|iini)  in  I'lilt's  disease,  inspection  of,  134 
Splint,  iJilhoth,  209 


SpUnt,  Bradford  hip,  231 

Bryant,  326 

Calliper,  267 

choice  of  an  ambulator}'  hip,  234 

convalescent  hip,  233 

Dane  hip,  232 

Gauvain's  back-door,  158 
posterior  suspensory,  159 
wheelbarrow,  159 

Hamilton's,  326 

Jones,  321 

Jones  crab,  286 

Judson's  traction  hip,  227 

Lister's,  322 

Lorenz,  229 

Macewan's  knock-knee,  275 

Middledorpf's,  308 

Phelps'  hip,  231 

plaster  hip,  228 

Ridlon  long  traction,  226 

Shaffer  hip,  226 

Taylor's  convalescent  hip,  235 

Thomas  hip,  224 
knee,  266 

traction  hip,  225,  231 

tubular  hip,  233 

walking  convalescent  hip,  235 
Spondyl  arthritis,  127 
Spondylolysthesis,  132 
Steel  brace,  flexible,  174 
Stiffness   in    tuberculous    disease    of   elbow- 
joint,  313 

hip-joint,  208 

joints,  46 
Stretcher  frame,  154 
Subcostal  abscess,  195 
Suction  hypexsemia,  75 
Supra-clavicular  abscesses  in  Pott's  disease, 

193 
Swelling   in   tuberculous   disease   of   ankle- 
joint,  283 

elbow-joint,  313 

jaw,  lower,  331 

joints,  48 

knee-joint,  261 

sacro-iliao  joint,  325 

tarsus,  291 
Symptomatology  in  diagnosis  of  bone  tuber- 
culosis, 51 

joint  tuberculosis,  54 
Symptoms  of  tuberculous  disease  of  anlile- 
joint,  282 

elbow-joint,  313 

hand  ami  foot  long  bones,  298 

hip-joint,  208 

knee-joint,  259 

shoulder-joint,  305 

spine,  127 
Synarthrodial  joints,  34 
Synchui\drosis,  34 
Synovectomy.  105 

of  knee-joint,  275 
Synovial  nienibrane,  structure  of,  35 

in  tuberculosis  of  joints,  35 
Synovitis,  acute  miliary  tuberculous,  39 


344 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


Synovitis,  chronic  tuberculous,  39 
fibrous  tuberculous,  41 
fungating  or  granulating  tuberculous,  40 

Tarsectomy,  complete  anterior,  293 

posterior,  294 
Tarsus,  tuberculous  disease  of  the,  290 
clinical  features,  291 
diagnosis,  292 
etiology,  290 
pathology,  291 
treatment,  292 
Taylor  brace,  170 

Taylor's     method     of     extension     in     bone 
tuberculosis,  102 
ring,  181 
Teeth  in  tuberculous  disease   of  lower  jaiv, 

331 
Temperature  in  joint  tuberculosis,  48 
Tenderness  in  tuberculous  disease  of  elbow- 
joint,  313 
joints,  48 
shoulder-joint,  306 
Terrier-Hannequin's   operation   in    hip-joint 

disease,  240 
Test,  heated  serum,  53 
inoculation,  5 
morphological,  4 
original  culture,  4 
special  culture,  5 
Theobald  Smith's,  5 
in  hip-joint  disease,  Kingsley's,  215 
Lovett's,  216 
Thomas,  213 
Tests,  tuberculin,  51 

in  diagnosis  of  joint  tuberculosis,  55 
Thickening  of  bone  in  tuberculosis,  44 
Thomas  coUar,  184 
Thomas  cuirass,  176 
Thomas  splint,  double,  152 
hip,  224 

modifications  of,  224 
knee,  266 
test  in  hip-joint  disease,  213 
Thorax  in  Pott's  disease,  changes  in,   119 

compensatory  changes  in,  142 
Thornton's  back  brace,  173 
Thymol -camphor  injections  in  cold  abscesses, 

79 
Tolerance  to  tuberculin,  87 
Traction  hip  splint,  225,  231 
modifications  of,  231 
in  hip-joint  disease,  222 
Transverse     process,     tuberculous     disease 

originating  in,  127 
Treatment,  hyperajmic,  73 
by  tuberculin,  results  of,  90 
of  bone  tuberculosis,  65 
conservative,  70 
general,  66 
operative,  92 
preventive,  65 
tuberculin,  85 
with  aUyl  sulphide,  85 
Mesbc,  85 


Treatment     of      bone     tuberculosis     with 
trypsin,  84 
of  cold  abscesses,  76 
aspiration,  simple,  77 

with  injection  of  medicaments,  78 
conservative  measures  in,  77 
simple  incision  with  drainage,  81 
without  drainage,  80 
of  joint  tuberculosis,  100 

summary  of,  104 
of  tuberculous  disease  of  ankle-joint,  285 
deformity,  287 
fixative,  '285 
general,  285 
local,  285 
operative,  287 
elbow-jomt,  conservative,  314 

operative,  315 
hand  and  foot  long  bones,  300 
hip-joint,  221 
ambulatory,  228 
complications,  240 
convalescent,  234 
deformities,  236 
fixative,  223 
operative,  242 
recumbent,  223 
jaw,  lower,  332 
knee-joint,  264 
ambulatory,  265 
conservative,  264 
fixative,  265 
general,  264 
Lannelongue's,  269 
operative,  271 
weight  extension,  265 
sacro-Uiac  joint,  326 
shoulder-joint,  307 
sinuses,  81 
skull  bones,  329 
spine,  147 

ambulatory,  163 
complications,  191 
deformity,  187 
general,  147 
-head  supports  in,  180 
local,  147 
mechanical,  147 
metal  braces  in,  170 
operative,  189 
recumbency,  147 

duration  of,  161 
routme,  185 
spinal  supports  in,  164 
tarsus,  292 
wrist-joint,  321 
Treves'    operation    for    abscess    in    Petit's 

triangle,  196 
Trypsin  treatment  of  bone  tuberculosis,  84 
Tubby's  spinal  pillow,  151 

support,  175 
Tubercle,  baeillary  emulsion,  86 
bacillus,  3 

changes  associated  with  the  original,  19 
formation  of  the  primary,  35 


GENERAL  INDEX 


345 


Tubercle,  histology  and  histogenesis  of  the 
original,  16 
intravascular,  16 
perivascular,  16 
Tuberculin,  choice  of,  88 

methods  of  administration  of,  87 
mode  of  preparation  of,  86 
reaction,  86 

results  of  inoculation  into  the  body,  86 
results  of  treatment  by,  90 
tests,  51 
treatment,  85 
Tuberculins,  varieties  of,  85 
autogenous,  89 
human  and  bovine,  89 
Tubereulo-opsonic  determination,  diagnostic 

use  of,  52 
Tuberculose  chamue,  25 
Tuberculosis,  etiology  of,  3 
congenital,  9 
predisposing  causes  of,  9 
Tuberculous  diaphysitis,  33 

disease  of  ankle-joint  {vide  Ankle-joint), 
281 
bone,  atrophic,  25 

blood-vessels,  changes  in,  21 
clinical  features  of,  H 
diagnosis  of,  50 
encysted,  22 

gross  pathological  varieties  of,  22 
hypertrophic,  26 
inliltnitinL',  23 
lamellar  changes  in,  20 
location  of  lesion  in,  30 
marrow  changes  in,  19 
methods  of  healing  in,  29 
pathology  of,  11 
periosteal  changes  in,  21 
possible  sequelae  of,  29 
prognosis  in,  64 

treatment  of  {vide  Treatment),  05 
elbow-joint  {vide  Elbow-joint),  312 
hand  and  foot  long  bones  {vide  Hand), 

297 
hip-joint  {vide  Hip-joint  Disease),  204 
jaw,  lower  {vide  Jaw),  330 

upper,  333 
joints,  changes  in  articular  cartilage  in, 
36 
blood-vessels  in,  38 
component  parts  in,  35 
synovial  membrane  in,  35 
umli'i'lying  bono  in,  37 
clinical  evidences  of,  41 

features  of,  46 
method  of  healing  in,  42 
imtholoyy  of,  34,  35 
perichondral  infiltration  in.  36 
prognosis  in,  64 
scquelie  of,  41 

subihondral  infiltration  of,  3(i 
treatment  of,  100 
varieties  of, 
knee-joint  {vide  Knee),  258 


Tuberculous  disease  of  malar  bone,  333 

ribs,  334 

sacro-iliao  joint  {vide  Sacro-iliac  Disease), 
324 

shoulder-joint  {vide  Shoulder),  304 

skull  bones  {vide  Skull),  328 

Spine  {vide  Spine),  111 

tarsus  {vide  Tarsus),  290 

wrist-joint  {vide  Wrist),  319 
Tubular  hip  splint,  233 
Tulase,  86 
Tumor  albus,  41 

Vaccine  tuberculin,  preparation  of,  86 
Vacuum  tuberculin,  86 

Varieties  of  joint  tuberculosis,  gross  patho- 
logical, 39 
osseous  tuberculosis,  22 
Vertebrje,  blood-supply  of,  12,  113 
general  structure  of,  112 
in  Pott's  disease,  changes  in  individual, 
113 
Vertebral  column  in  Pott's  disease,  changes 
in,  116 
spine,  tuberculosis  originating  in,  127 

Walking  in  hip-joint  disease,  alterations  in, 

211 
Wasting  in  tuberculous  disease  of  shoulder- 
joint,  306 
Weight  extension  in  tuberculous  disease  of 

knee-joint,  265 
White  swelling,  41 
Whitman  stretcher  frame,  154 
Wire  chin  rest,  182 
Wolff-Eisner's     theory     of     the     tuberculin 

reaction,  87 
Wood  for  bone  fixation,  72 
Wright's  treatment  of  sinuses,  84 
Wrist-joint,  anatomy  of,  319 
excision  of,  322 
tuberculous  disease  of,  319 

clinical  features  of,  320 

diagnosis  of,  321 

etiology  of,  319 

pathology  of,  319 

prognosis  of,  321 

treatment  of,  321 

X-ray   appearances  in   negatives   of   tuber- 
culous bones,  58 
examination  in  diagnosis  of  bone  tubercu- 
losis, 51 
joint  tuberculosis,  55 
hi])joint  disease,  218 
Poll's  disease,  142 
spina  ventosa,  299 
of  the  ankle-joint,  284 
negative  apixinrances   in   special   typos  of 
bono  tuberculosis,  60 
tuberculous  disease  of  joints,  (il 
treatment  of  tuberculous  lesions,  76 

Zinc-chloride  injoctions  in  cold  abscesses,  79 


INDEX    OF    AUTHORS 


Abbott  (E.  G.),  255 

Achard  (C),  8 

Adam  (S.  D.),  203,  238 

Adams  (G.  E.),  107 

AJamartine,  33 

Alapy  (H.),  256 

Albee  (F.  H.),  190,  203 

Albert  (Maurin),  43 

Allen  (H.  P.),  200 

Aller  (F.  H.),  327 

AlUson  (H.),  201,  203 

Alquier  (L.),  U4,  199,  200 

Alton,  Lord  Mayor  Treloar's  Home,  07 

Alusandre  (G.),  56 

Anburg,  31 

Anderson  (F.  C),  254 

Andion  (P.),  202 

Andrews  (C.  R.).  327 

Andrieu,  202 

Angel  (A.  M.),  199 

Anzilotti  (G.),  43 

Aree  (J.),  42 

Ai-din,  199 

Armour  (D.),  199,  200 

Armstrong,  254 

Arnaud  (L.),  57 

Ascenze  (E.),  201 

Atherton  (H.  B.),  200 

Baden  (C),  108 

Badris,  203 

Bailleul  (Louis),  303 

Balamic,  201 

Baldwin,  279 

Barbarin  (P.),  108,  256,  278,  279,  335 

Barbe,  254 

Barbiii,  57 

Barker  (A.  E.),  243 

Barney  (.1.  U.),  311 

Barton,  239 

Bastianelli  (R.),  199 

Batier,  201 

Batut  (L.),  32,  335 

Biilz-ner,  84 

Baumgartcn,  9 

Beau  (V.),  279 

Beck  (E.  G.),  82,  96 

Beely,  137 

Behriiig  (L.  von),  6 

Belliam,  256 

Bulhant,  9S 

Bencko,  200 


Benet  (A.),  33 

Bennet  (W.),  98 

Benoit  (C),  256 

Berger,  280 

Berry  (J.  M.),  201 

Berry  (W.  T.),  253,  257 

Beule  (F.  De),  257 

Bidaux  (R.),  256 

Bidou  (A.),  279 

Bier,  73,  83,  104 

Bietzengieger,  85 

Binet  (A.),  257 

Bird  (Golding),  335 

Blanchard,  82 

Bogardus  (F.  B.),  327 

Bonnamour  (S.),  200 

Bosquette,  323 

Bourgeois  (Henri),  296 

Bourgeois  (Paul),  335 

Boveri  (P.),  200 

Bowlby  (Sir  A.  A.),  242,  257 

Boye,  42 

Braokett  (E.  G.),  57,  169,  199 

Bradford  (E.  H.),  32,  153,  188,  252,  255,  257 

Bredi  (C.  S.),  57 

Brcnda  (K.),  8 

Breton  (Prescott  le),  83,  99 

British  Royal  Commission,  4,  6 

Broca  (A.).  33,  42,  63,  200,  254,  255,  279, 

295 
Brora  (L.  T.),  202 
Brown  (E.  M.),  32 
Bruns,  221 
Buckhardt  (H.),  6 
Budde,  302 
Bullock,  53 
Burghard,  272 
Burguet  (P.),  108 
Buzzard  (E.  F.),  199 

Cabanis  (E.),  279 

Cadburv  (\V.  \V.),  31 

Cadwaladcr  (W.  B.),  201 

Caldwell  (C.  B.),  57 

Calmette  (C),  6,  51 

Cal6t,  79,  83,  103,  107,  187,  188,  189,  200, 

202,  255,  257.  287 
Calve  (.1.),  79,  108,  203,  255,  256 
Campbell  (\V.  C),  254 
Caspari,  68 
Caspor  (M.),  200 
Cayro  (E.),  254 


347 


348 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


ChaUer  (A.),  199 

Chalier  (X.),  108,  199 

Chaput,  98,  295 

Charitonoff  (S.),  33 

Charrur  (A.),  279 

Cheyne  (Sir  W.  W.),  37,  199,  218,  272 

Chipault,  187 

Chlumski  (V.),  201 

Cilley  (A.  H.),  107 

Clarke  (J.  J.),  202,  280 

Codet-Boisse,  99 

CoUenet  (A.),  99 

Colvin  (A.),  57 

Condray  (P.),  256,  257 

Cone  (S.  M.),  31 

Coppen- Jones  (A.),  5 

Cotti  (G.),  201 

Cotton,  188 

Courmont  (P.),  56 

Cowden  (C.  H.),  32 

Coyon,  80 

Crespolti  (L.),  107,  280 

Croquet  (C.  du),  279 

Cumston  (C.  G.),  318 

Cushway  (B.  C),  63 

Dalchcf  (J.),  201 
Dane,  232 
Daniel  (P.  L.),  42 
D'Antona  (A.),  254 
Davidson  (J.  T.),  57 
Davies,  172 

Davis  (H.),  202,  226,  280 
Dawbarn  (R.  H.  M.),  318 
Defais  (A.),  278 
Delbet,  327 
Delchef  (J.),  256 
Deloux,  199 
Deltart,  199 
Demoulin,  41 
Depos,  99 
Dervaux,  200 
Diakonow,  272 
Dieffenbaoh  (VV.  H.),  62 
Dittrieb,  335 
Dobrotworski,  190 
Doche  (J.),  108,  256 
Dorset  (M.),  4 
Doumer  (E.),  98,  108 
Drem  (D.),  279 
Duchanip,  311 
Ducroquct  (C),  255 
Ducuing  (P.),  329 
Dumas,  42 
Dunne  (F.),  98 
Duvergey  (J.),  279 

Ebner,  138 

Edinburgh  Sick  Children's  Hospital,  9, 

102,  223,  281,  282 
Edmunds  (A.),  200,  280,  295,  296 
Ehringhaus  (0.),  254 
Elmslie  (R.  C),  254 


10, 


Elsberg  (C.  A.),  199 

Ely  (L.  W.),  42,  98,  108,  202 

Epstein,  201 

Ernst  (H.  C),  i 

Esau  (P.),  57 

Eversole  (H.  0.),  92,  99 

Ewald  (P.),  62,  295 

Ewart  (W.),  201 

Ewing  (W.  G.),  32 

Feiss  (H.  D.),  253,  256 

Ferguson  (A.  H.),  280 

Ferre,  200 

Fibiger  (J.),  4 

Fidon,  279 

Fiessinger,  80 

Finberg  (A.  H.),  42 

Fiolle,  254 

Fioravanti,  203 

Fisher,  151 

Forbes  (A.  M.),  201.  202,  255 

Forssel  (G.),  62 

Forster,  91 

Fortin,  257 

Foulatier,  200 

Frank  (F.),  295 

Franzoni,  98 

Fraser  (J.),  6,  26,  32,  50,  89,  114,  191,  206 

Frazer,  202 

Freiberg  (A.  H.),  99,  202 

Frenella  (Dupuy  de),  279 

Fress  (H.  0.),  202 

Freund  (L.),  63 

Friedrich  (P.  L.),  8 

FroeUeb,  202,  203 

Galeazzi  (R.),  201 

Gallani  (A.  E.),  203 

Gallie  (\V.  E.),  200,  202,  254 

Gallocun,  279 

Gangele  (K.),  203 

Gangolphe,  42,  304 

Garri  (C),  108 

Garie,  40 

Gauthier  (L.),  199 

Gauvain  (H.  J.),  72,  79,  157,  158,  159,  162, 

164,  178,  201,  203 
Gayet,  200 
Genevier,  56 
Genne,  327 

Gerard  (C.  M.),  254,  323 
Gibney  (V.  P.),  112,  221,  255,  256,  280 
Gilette  (H.  J.),  311 
Giletti  (A.  J.),  98 
Gillespie  (E.),  99 
Giminez  (L.  H.),  32 
Glaessner,  91 
Godernel,  107 
Goldmann,  41 
Goldschwind  (F.),  327 
Goldthwaite  {J.  E.),  32,  169,  189 
Graham  (J.),  253 
Granger  (A.),  62 


INDEX  OF  AUTHOES 


349 


Gray  (H.  M.),  90 

Green  (R.  M.),  303 

Greenberg  (H.  J.),  257 

Greifswald  Surgical  Polyclinic, 

Gross,  335 

Gruber  (G.),  98 

Gueit,  295 

Guerin  (A.),  7,  279 

Guermonpiez,  107 

Guscff  (P.  F.),  200 

Guyot,  200 

Haar  (F.),  327 
Hadra  (B.  K.),  189 
Hahn,  282 
Hamburger,  6 
Hammond  (R.),  279 
Hammond  (W.  N.),  279 
Hancock  (I.  H.),  318 
Harris  (L.  H.),  1)0 
Harris  (W.),  201 
Hartwell  (J.  A.),  318 
Hastings  (T.  W.),  99 
Hatel  (E.  S.),  201 
Hauser,  108 
Hayes,  203 
Heckmann  (J.),  318 
Heidenhain,  19-t 
Heinecke  (F.  K.),  302 
Helbing,  156 
Hendrox  (G.),  256 
Henoque,  37 
Hermann,  85,  257 
Heuss,  4,  6 

Hibbs  (Russcl  H.),  190,  203 
HUl  (R.),  99 
HUton  (John),  145 
Hoeftmann,  108 
Ho£Fa  (A.),  91,  155,  255 
Hohmeier,  91 
Hoke  (M.),  327 
Holmcr  (15.),  57 
ilolt,  ti 

Horand  (R.),  254 
Horwitz  (A.  E.),  57 
Horwitz  (H.  S.),  98 
llouzcl,  253 
Howship,  20 
Huollon  (van),  91 
Huot<r,  243 
iluisnmna,  221 
Huntington,  250 

Impallomeni  (G.),  279 
Ingram  (J.  W.).  257 
Isclin  (11.),  70,  318 

Jack  (H.  P.),  57 
Jacobi,  B 

Jacobs  (C.  M.),  255 
Jacobsohn  (E.),  02 
.Jacques  (U.),  335 
.laegiT,  1 1 2 
Jankouski  (I.  I.),  254 


104 


Jara  Mills  Bruce  (R.),  254 

Jeanne,  257 

Jensen  (C.  0.),  4 

Jiminez  (L.),  107 

Johnston  (R.),  200,  279 

Jones  (R.),  32,  188,  240,  286,  308,  314,  321, 

326 
Jorion  (E.),  32,  200 
Judet,  279 

Kaatoven  (J.  J.  A.  van),  279 

Kantor  (M.),  107 

Keith  (J.  R.),  42 

KeUock  (T.  H.),  310 

Keppler  (C.  R.),  250 

Kingsley  (G.  L.),  215 

Kirk  (T.  S.),  203 

Kirmisson,  78,  128,  254,  255,  335 

Klarfekl  (B.),  199,  200 

Klapp,  75,  83,  84 

Koch,  3,  49 

Kocher,  194,  246,  273,  287,  294,  317 

Koenig,  25,  26,  36,  41,  245,  257,  287,  289, 

305 
Kofmann  (S.),  203 
Koop  (E.  J.  Wyn),  56 
Kossel  (H.),  4,  6 
Krause  (F.),  7,  89,  287 
Krurawiede  (C),  4,  6 
Kunner,  323 
Kuzmin  (Y.  U.),  303 

Lancial  (D'Arras),  43 

Langc  (B.),  202,  203 

Lango  (F.),  108,  190 

Langomak,  250 

Langcnbeck,  245 

Langeron,  33 

Lannelongue  (0.  M.),  8,  38,  HI,  255,  269 

Lanz  (0.),  279 

Larny  (L.),  254 

Latreillo  (E.),  200 

Laurens,  80 

Lauwers,  108 

Lederet  (Q.),  108 

Legg  (A.  T.),  39,  42,  212 

Lehr  (H.),  280 

Lelievro  (H.),  203 

Lenhart  (H.),  280 

Lentaigne,  32 

Lephro  (P.),  295 

Lerichc  (R.),  32 

Lousdon  (Pels),  303 

Lexer,  1 1,  30.  278,  297 

Liebcntli.'d,  254 

Liprat  (.1.  U.  G.),  335 

Loowy,  08,  98 

Logan  (G.  K.),  199 

Lorenz,  229 

Lortat  (.).  L.),  31 

Lossen  (W.),  318 

Lovett  (R.  VV.),  109,  202,  210,  217.  252 

Lozano  (R.),  98,  108,  302 

Lubenau  (C),  4 


350 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


Macdonald  (H.  K.),  253 

Macewan  (Sir  William),  13,  108 

Macgowan,  89 

Machard,  99 

Mackenzie  (D.),  335 

Ma£fel,  257 

Maixe,  255 

Marfan  (A.  B.),  32 

Marie,  303 

Marion  (G.),  255 

Marmorek,  91 

Marsh-Howard,  236 

Marshall  (H.  W.),  108 

Marshall  (V.  F.),  255 

Martens  (W.),  107 

Martinesco  (G.),  199 

Mason  (F.  S.).  202 

Massabrian,  295 

Massini  (G,),  32 

Matthews  (F.  S.),  33,  279 

Matthews  (J.  G.),  201 

Mauclaire,  25,  26,  32,  255 

Maurin,  108 

Mayet  (H.),  98,  256 

M'Burncy  (C),  257 

Mehans,  57 

Mehnarto,  92 

Melchior  (E.),  33,  57 

Menard  (V.),  79,  108,  115,  119,  126,  157, 

Menciere  (L.),  107,  254,  256 

Merguet  (H.),  202 

Metchnikoff,  18 

Mette  (B.  F.  van),  32 

Meyer  (W.),  295 

M'llhenny  (P.  A.),  255 

Miller  (A.  G.),  207,  272 

Miller  (H.  B.),  99 

milcr  (M.  B.),  31 
Minchin  (W.  C.),  85 
Mitt  (J.  J.),  254 

Mivea  (J.),  199 
M-Murphy  (N.  W.),  254 
M'Nurten,  98 

Moeller  (A.),  5 

Moignet  (Emile),  335 

Moniat,  Le,  107 

Monod  (G.),  202 

Monot,  202 

Moon  (R.  S.),  200 

Moore  (G.  C),  201 

Moreau  (J.),  280 

Moreston,  335 

Moro  (G.),  42,  52 

Morland,  88 

Morris  (R.  T.),  310 

Mosetig-Moorhof,  95 

Mounguand  (E.),  33 

Much,  5 

Miiller  (W.),  7,  08,  107 

Murpen  (T.  K.),  296 

Murphy  (J.  B.),  96,  251,  256,  277,  335 

Neff  (F.  C.),  201 
Neidert,  146 


194 


Neil-Pliilippe,  107 

Nelaton,  23,  251 

Neuber,  95 

Neuwall  Hospital  for  Surgical  Tuberculosis, 

67 
Newman  (W.),  203 
Nichol  (A.  G.),  42 
Nott  (J.  J.),  42 
Nove  Josserand,  98 
Nutt  (J.  J.),  99 
Nyrop  (E.),  200 


Oberst  (Adolf),  108 

Ochsner  (E.  H.),  99,  107,  287,  289 

Ogilvy  (C.),  57,  99,  257 

Oilier,  27,  28,  322 

OlUvier,  280 

Openshaw  (T.  H.),  201,  203 

O'ReiUy  (A.),  57 

Osgood  (C.  B.),  32 

Ostensarken  (E.  von  der),  200 

Osterham  (K.),  255 

Packard  (G.  B.),  99,  256 

Pages,  329 

Painter  (C.  F.),  32,  90,  98,  99,  107 

Panton  (K.  D.),  202 

PaoU  (A.),  31 

Paquet  (A.),  57 

Parechet  (V.),  327 

Park  (W.  H.),  4,  6 

Parry  (L.  A.),  203 

Parsons  (W.  B.),  145,  201 

Peckham  (F.  E.),  279 

Pellissier,  199 

Peltesohn  (S.),  43 

Pengree  (H.  A.),  107 

Peollett,  107 

Peraire,  311 

Perkins  (J.  W.),  271 

Perthes  (G.),  108 

Peterka  (H.),  108 

Peters,  33 

Petrofi,  89 

Ptahler  (G.  E.),  63 

Phelps,  80,  156,  231 

Philbert,  63 

Pic  (A.),  200 

Picquo  (R.),  327 

Pietrzikowski  (E.),  8 

Pirie  (G.  A.),  63 

Pirquet,  von,  52 

Plimmer  (W.  W.),  99 

Pohl  (F.),  108 

Poncet  (A.),  32,  56,  200 

Porter  (J.  L.),  92.  99,  108 

Poughe  (H.  A.),  255 

Poulet,  38 

Power  D'Arcy,  212 

Prevost,  99 

Primrose  (A.),  107 

Privat  (T.),  57 


INDEX  OF  AUTHORS 


351 


Quervain,  76 

Quiim  (L.  C),  92,  99 

Eabadean,  42 
Rabinowitsch  (L.),  i 
Rankin  (H.  B.),  255 

Rappenau   Sanatorium   for   Surgical   Tuber- 
culosis, 67 
Rauenbusch  (Z.),  201 
Ra venal  (II.  P.).  4 
Raw  (Nathan),  89,  90 
Ray  (J.  H.),  254 
Raj'naud,  199 
Redard  (P.),  98,  188,  203 
Reise,  41 
Remer  (H.),  318 
Renard  (L.),  200 
Reverden  (J.  L.),  323 
Reynier,  295 
Rheinhardt  (A.),  42 
Rheuter,  56 
Rich  (E.  A.),  202 

Ridlon  (J.),  42,  82,  99,  286,  308,  314,  326 
Ridolfi,  31 

Rieger  (K.  G.  A.  G.),  200 
Rives  (A.),  279 
Riviere  (C),  53,  87,  88 
Rocher  (H.  L.),  255 
Roederer  (C),  201 
Roepker  (0.),  302 
RoUier  (A.),  08,  98 
Rooth  (H.  C),  257 
Rosenberger  (K.  C),  9 
Ross  (G.  C),  318 
Roth  (P.  B.),  201,  203 
Rowlands  (R.  P.),  254,  335 
Royal  Commission  (British),  4,  6 
Ruchmann  (M.),  63 
Rudes-Jiccinski  (J.),  107 
Rugh  (J.  T.),  203,  253 

Saarfils,  254 
SabcUa  (P.),  202 
Sablo  (J.),  200 
Sachs  (B.),  203 
Salaghi  (M.),  255 
Salve  (W.  E.),  254 
Salvia  (K.),  8 
Sarfels  (C),  200 
Savariana,  255,  256 
Saxe  (A.),  200 
Sayre,  226,  239 
Schaffer  (K.),  107 
Schapp,  172 
Schedc,  96 
Schonkcr,  91 
Schilling,  198 
Schlabowski.  36 
Schloe  (11.),  2.">4 
Schliiselcr  (K.),  201 
Schonicdler  (\'.),  318 
Schuflel,  18 
SchiUler  (M.),  7 


Schulthess,  202 

Schulz  (G.  B.),  253 

Schwartz  (A.),  57 

Schwatt,  256 

Scudder  (C.  L.),  311 

Seilhan  (Fran^oise),  329 

Selby  (C.  D.),  202 

Senn,  96 

Sever  (J.  W.),  296,  311,  318 

Sexton  (L.),  254 

Shaffer,  182 

Shands  (A.  R.),  108,  255 

Sharpev,  13 

SherUe"(S.  G.),  279 

Sherman  (H.  M.),  99 

Sick  Children's  Hospital  (Edin.),  9,  10 

Silver  (D.),  99 

Skinner  (C.  H.),  02,  63 

Smith  (E.  H.),  254 

Smith  (Maynard),  90,  99 

Smith  (Theobald),  4,  5 

Smoler  (F.),  33 

Snively  (J.  H.),  256 

Soutter  (R.),  255 

Spangenberg,  85 

Spengler,  89 

Starr  (C.  L.),  200 

Steinman,  302 

Stern  (W.  G.),  108,  202,  255 

Sternhardt  (I.  D.),  279 

Stich  (R.),  295 

Stienar,  201 

Stienhardt  (I.  D.),  201,  254 

Stiles  (H.  J.),  80,  96,  97,  195,  248,  249,  252, 

274,  275,  276,  277,  282,  288,  289,  318 
StiU,  56 
Stillman,  269  . 
Strauss  (M.),  108 
Streda  (H.),  327 
Stuia  (I.  D.),  201 
Subblev  (E.  F.),  57 
Swan  (R.  L.),  278 
Swett  (P.  P.),  57 
Swift  (H.),  107 
Swyiighcdauw,  279 

Tavlor  (C.  F.),  170,  226 
Taylor  (H.  L.),  257 
Taylor  (K.  T.),  98,  102 
Ternier,  200 
Terrier-Hannequin.  240 
Textor,  272 
Thierv  (P.),  98 
Thomas  (B.  11.),  99 
Thompson  (G.  Ritchie),  74 
Thorndike,  1 12 
Thornton,  173,  233 
Tik  (V.  A.),  42 
Tilmann,  104 
Tis.sot  (F.),  200 
Tixier,  32,  295 
Todd  (C.  K.),  107 
Tocpel  (T.),  32 
Touchot  (F.  II.),  200 


352 


TUBERCULOSIS  OF  THE  BONES  AND  JOINTS 


Tourneaux  (J.  P.),  33,  329 
Townsend,  120 
Traversier,  200 
Treboulet  (H.),  42 
Trcloar  (Lord  Mayor),  67 
Treves,  196 
Tridon  (P.),  200 

Tubby,  7,  77,  112,  119,  151,  175,  186,  IS 
191,  261 

Vacorand  (H.),  33 

Van  Hook,  324 

Van  Hucllen,  91 

Van  Mette  (B.  F.),  32 

Vassalin  (C.  N.),  295 

Vendova  {R.  DaUa),  98 

Verneuil  (H.),  98 

Vignard  (P.),  33,  98,  202,  256,  257 

ViUard,  323 

Villemin,  5,  255 

Vinant  (E.),  257 

Vincent,  297 

Virchow  (H.),  199 

Vogel  (K.),  201 

Vogelmann  (R.),  31 

Volkmann,  13,  25,  26,  272,  304 

Von  Behring  (L.),  6 

Von  Bonsdorff  (H.),  256 

Von  Pirquet,  52 

Vreese  (C.  de),  279 

Vulpuis  (0.),  108 

Wagner,  221 

Walderstroom  (H.),  57,  255 
WaUace  (C),  98,  201 
VVallis  (F.  C),  197,  200 


Walther,  295 

Waltiker,  279 

Walton  (A.  J.),  99 

WassiUew  (M.  A.),  198,  200 

Waterman,  112 

Weber  (A.),  4,  6,  256 

Weeks  (S.  W.),  254 

WeUs  (A.),  201 

WetherhUl  (H.  G.),  99 

Wheeler  (W.  I.  de  C),  327 

Whitbeck  (B.  H.),  202 

Whitman,  172,  203,  204,  229,  281 

Wiener  (A.  C),  202 

WUchet  (J.),  256 

Willard  (de  F.),  99,  264 

Wills  (W.  le  M.),  255       . 

Wibex  (C),  98 

Wilson  (H.  A.),  9,  74,  108,  256 

WUson  (H.  B.),  107 

Wolbach  (S.  B.),  4 

Wolff-Eisner,  87 

WooUey  (P.  G.),  42 

Wright  (G.  A.),  69,  84,  87,f212,'275 

Wullstein,  111,  118 

Wyeth  (J.  A.),  202,  254 

Wyn-Koop  (E.  J.),  56,  255 

Yeo  (Burney),  69 
Yoiing  (G.  B.),  137 
Young  (J.  K.),  62,  201 

Zeldovich  (Y.  B.),  279 
Zelhneyer,  335 
Zhachenko  (H.  S.),  311 
Zuntz,  68 


THE    END 


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